Riverwood Healthcare & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Starke, Florida.
- Location
- 808 S Colley Rd, Starke, Florida 32091
- CMS Provider Number
- 105488
- Inspections on file
- 24
- Latest survey
- August 29, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Riverwood Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
Staff did not consistently use PPE or perform hand hygiene as required, particularly when caring for residents on enhanced barrier precautions and during medication administration. Multiple staff members were observed entering rooms, providing care, and handling equipment without donning gowns or sanitizing hands, even for residents with indwelling devices or respiratory equipment. Facility policies required these precautions, but staff interviews revealed lapses and uncertainty about procedures.
Three residents prescribed opioid pain medications did not consistently receive their scheduled doses due to pharmacy delays, lack of access to the automated medication dispensing machine, and insufficient staff training or orientation. Residents reported increased pain and withdrawal symptoms, while staff interviews revealed confusion about medication refill processes and emergency access. Documentation of missed doses and communication with physicians was often incomplete or missing, resulting in inadequate pain management.
Nurses and nurse aides lacked the necessary competencies to provide care that maximizes each resident's well-being, resulting in care that did not fully support residents' health and quality of life.
Nurse staffing data was not posted daily as required, with an outdated staffing form observed and staff confirming that the correct report was not displayed on the designated day. The DON and Staffing Coordinator described a process for posting reports, but a lapse occurred, resulting in noncompliance with daily posting requirements.
Surveyors found that food items, including expired milk, undated sandwiches, and unlabeled liquids, were improperly stored in two nourishment rooms. Staff interviews revealed confusion over responsibility for labeling and dating food, and facility policy requires proper labeling for stored food items.
A resident with multiple chronic conditions experienced a code event and was pronounced dead by EMS after resuscitation efforts by staff. There was no documentation in the medical record regarding the code, resuscitation efforts, or the resident's death, despite facility policy requiring such documentation. Staff and the DON confirmed the absence of required documentation.
A resident with cognitive impairment and ADL/self-care deficits was repeatedly observed in bed without the call device within reach, as required by facility policy and the resident's care plan. The call device was found either hanging on the wall by the resident's feet or on the floor, and staff confirmed it should have been accessible at all times.
A facility failed to ensure accurate discharge assessments for a resident with multiple diagnoses, including diabetes and hypertension. The resident was discharged to an assisted living facility, but the MDS assessment incorrectly documented a discharge to a hospital. The MDS Coordinator confirmed the error and stated that the facility lacked a specific policy for MDS discharge assessments, relying on the RAI instead.
The facility failed to secure medications properly, with residents found with medications at their bedside without physician orders for self-administration. An RN left medications unattended, and the DON stated that medications should not be left at the bedside. These actions indicate non-compliance with the facility's medication storage policy.
The facility failed to properly store, label, and discard food items in the dietary department, as observed during a survey. Unlabeled and outdated food items were found in the walk-in cooler and storage room, contrary to facility policies. The Dietary Manager confirmed these deficiencies.
A resident with schizophrenia and other conditions experienced a health decline, necessitating a hospital transfer. The facility failed to document the transfer properly, missing key records like the transfer form and physician order. Staff interviews revealed confusion over the documentation process, and despite efforts to locate the paperwork, it remained incomplete.
A facility failed to ensure proper hand hygiene during medication administration and did not properly store reusable medical equipment. An LPN was observed not performing hand hygiene before or after administering medications to residents, contrary to facility policy. Additionally, a nebulizer in a resident's room was not stored correctly, with tubing undated and the face mask uncovered, violating infection control protocols.
Failure to Adhere to Infection Prevention and Control Protocols
Penalty
Summary
Staff failed to consistently use appropriate personal protective equipment (PPE) and perform hand hygiene as required by facility policy and procedure, particularly when providing care to residents on enhanced barrier precautions (EBP) and during medication administration. Multiple observations documented staff entering resident rooms, including those with EBP signage and available PPE, without donning gowns or performing hand hygiene. Staff were seen donning gloves without prior hand hygiene, providing direct care such as flushing midline catheters, administering medications, and performing incontinence care, then removing gloves and exiting rooms without hand hygiene. In several cases, staff proceeded to handle medication carts, computers, and other residents without sanitizing their hands between tasks. Residents involved included those with significant infection risks, such as individuals with indwelling medical devices (e.g., midline catheters, artificial joints, feeding tubes) and those requiring respiratory care equipment. For example, one resident with a right upper arm midline catheter and a history of joint replacement and surgical wound complications was cared for by staff who did not follow EBP protocols or hand hygiene requirements. Another resident's oxygen concentrator humidification bottle was observed sitting on the floor, contrary to infection prevention standards. Staff interviews revealed a lack of understanding or recall of EBP requirements and hand hygiene protocols, with several staff acknowledging lapses or uncertainty about the correct procedures. The facility's policies on EBP and hand hygiene, last revised in August 2025, require the use of gowns and gloves for high-contact care activities and mandate hand hygiene before and after resident contact, after glove removal, and before handling medications or invasive devices. Despite these policies, repeated failures were observed across multiple staff members and shifts, including LPNs and CNAs, during medication administration, vital sign collection, respiratory care, and meal assistance. These deficiencies were confirmed through direct observation, staff interviews, and review of facility policies.
Failure to Provide Consistent Pain Management Due to Medication Access and Documentation Issues
Penalty
Summary
The facility failed to provide adequate pain management for three residents who were prescribed opioid pain medications. Multiple instances were documented where residents did not receive their scheduled opioid medications due to issues such as pharmacy delays, lack of access to the automated medication dispensing machine, and insufficient staff knowledge or training regarding medication refills and emergency access procedures. In several cases, the medication administration record (MAR) indicated missed doses coded as 'other/see nurses note,' but corresponding nursing notes were often missing or incomplete. Residents reported experiencing increased pain, withdrawal symptoms, and anxiety as a result of missed doses, and staff interviews revealed confusion about protocols for obtaining and administering controlled substances when regular supplies were depleted or inaccessible. For one resident with a history of spinal stenosis, diabetic neuropathy, and chronic pain, there were repeated missed doses of oxycodone due to pharmacy delivery delays and inability to access the emergency drug kit, especially when only agency nurses were present who lacked the necessary access. The resident described experiencing withdrawal symptoms and increased anxiety during these periods. Staff interviews confirmed that agency nurses often did not know the refill process or lacked access to the emergency supply, and documentation of physician notification or alternative pain management was inconsistent or absent. The facility's own protocols required timely preparation of prescriptions and notification of supervisors or the DON when medications were unavailable, but these steps were not reliably followed. Two other residents with chronic pain conditions also experienced missed or held doses of opioid pain medications, with documentation gaps and lack of clear communication with physicians or pharmacy. In some cases, medications were held due to resident refusal or drowsiness, but required documentation was not completed. Staff interviews indicated a lack of orientation and education for agency nurses, and some staff were unaware of emergency access procedures or on-call contacts. The facility's failure to ensure consistent access to pain medications, proper documentation, and adherence to pain management protocols resulted in residents not receiving necessary pain relief as ordered.
Inadequate Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified based on observations and findings that staff lacked appropriate skills or knowledge required to meet the individualized needs of residents. This failure resulted in care that did not fully support the residents' overall health and quality of life. The report specifically notes that the staff's competencies were insufficient to ensure that every resident received care tailored to their needs, impacting their well-being.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily as required. During an observation, the Daily Nursing Staffing Form displayed was found to be dated several days prior, rather than reflecting the current date. Interviews with the DON and Staffing Coordinator revealed that the Staffing Coordinator was responsible for posting the report on weekdays, while the Weekend Receptionist handled this task on weekends. The Staffing Coordinator reported that she prepared the weekend reports in advance for the Receptionist to post each day. However, it was confirmed that the correct staffing report was not posted on the observed morning, indicating a lapse in the daily posting process.
Failure to Store and Label Food Items Properly in Nourishment Rooms
Penalty
Summary
Surveyors observed that food products in two nourishment rooms were not stored and maintained in a safe and sanitary manner. Specifically, five chocolate milks with expiration dates that had already passed were found in the refrigerator, along with a Tupperware container and a bag of sandwiches that were both undated and unlabeled. Additionally, a 20-ounce cup half full of liquid was found without a label or date, and two fortified nutritional shakes were also undated. These observations were made during routine checks of the nourishment rooms. Interviews with facility staff revealed a lack of clarity regarding responsibility for labeling and dating food items. The Certified Dietary Manager in training was unaware of who was responsible for ensuring all food was properly dated and labeled. The Administrator stated that nursing staff should be responsible for dating and labeling food items in the nourishment rooms, while the kitchen is responsible for dating the shakes. The Regional Food Service Manager indicated that dietary staff are responsible for cleaning the refrigerators and freezers daily, but the facility is responsible for dating and labeling food items. Review of the facility's policy confirmed that staff are required to label foods with the resident's name and current date when food is intended for later consumption.
Failure to Document Code Event and Resident Death in Medical Record
Penalty
Summary
The facility failed to accurately and completely document the medical record of a resident who experienced a code event and subsequently died in the facility. The resident had multiple diagnoses, including hypertension, anemia, heart failure, dementia, schizoaffective disorder, and a history of COVID-19. On the day of the incident, staff responded to a code in the resident's room, performed CPR, and continued resuscitation efforts until EMS arrived and pronounced the resident deceased. Despite these events, there was no documentation in the resident's nursing progress notes regarding the resuscitation efforts, the code event, or the resident's death. Interviews with nursing staff and the Director of Nursing confirmed that there was no code sheet documentation or detailed note in the resident's chart about the incident. The facility's policy required that all services provided, changes in condition, and incidents be documented in the clinical record. However, a review of the medical record and interviews revealed that these requirements were not met, as there was no record of the code or the resident's death in the clinical documentation.
Failure to Ensure Call Device Accessibility for Resident with ADL Deficit
Penalty
Summary
A deficiency was identified when a resident with an ADL/self-care performance deficit and cognitive impairment was repeatedly observed without access to a call device while in bed. Multiple observations over several days documented that the call device was either hanging on the wall by the resident's feet, not within reach, or on the floor at the foot of the bed. The resident was observed in various states of dress, sometimes wearing only a brief, and at times with no blankets on the bed. The overbed table and breakfast tray were also noted to be positioned in ways that did not facilitate access to the call device. Interviews and record reviews confirmed that facility policy requires call lights to be within easy reach of residents when in bed or confined to a chair. The resident's care plan specifically included an intervention to encourage use of the call bell for ADL assistance. The DON confirmed that the call device should have been within reach at all times, but this was not consistently ensured for the resident in question.
Inaccurate Discharge Assessment Documentation
Penalty
Summary
The facility failed to ensure that the assessments accurately reflected the resident's status for a resident reviewed for discharge. The resident was admitted with diagnoses including type II diabetes mellitus, hypertension, osteoarthritis, depression, and anxiety disorder. The discharge summary indicated that the resident was discharged to an assisted living facility, and progress notes confirmed the resident left without distress or concerns. However, the Minimum Data Set (MDS) Discharge Return Not Anticipated assessment inaccurately documented the resident as being discharged to a short-term general hospital. During an interview, the MDS Coordinator confirmed the error and noted that the facility did not have a specific policy for completing MDS discharge assessments, instead following the Resident Assessment Instrument (RAI).
Medication Security Lapses in Facility
Penalty
Summary
The facility failed to ensure medications were secured in three of five hallways, as observed during a survey. In one instance, a resident had Dorzolamide HCl Solution at his bedside without a physician's order to self-administer, despite the resident's claim of using the medication himself. The RN confirmed the absence of an order for self-administration, and the Director of Nursing expressed that medications should not be left at the bedside. The facility's policy requires nursing staff to maintain medication storage in a safe manner, which was not adhered to in this case. In another instance, a resident had a medication cup with seven pills on his overbed table, stating he had not taken them due to personal preferences. The RN admitted to leaving the medications unattended while addressing other tasks. Similarly, another resident was found with a cup containing four pills on his bedside table, intended to be taken later, without a self-administration order. These observations indicate a failure to secure medications properly and ensure compliance with physician orders for self-administration.
Deficiency in Food Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage, labeling, and discarding of food items in the dietary department's walk-in cooler and stock/storage room. During an initial tour of the kitchen, surveyors observed 93 bowls of lemon gelatin with a use-by date that had already passed, as well as a tray of 70 glasses of iced tea and containers of vegetables and soup, all without identifying labels or dates. The Dietary Manager (DM) confirmed these observations and acknowledged that outdated foods should have been discarded and that all containers should be labeled and dated. In a follow-up tour, additional issues were noted, including packages of hotdog buns, hamburger buns, and sliced bread with no open dates, as well as partial containers of oil and instant mashed potatoes without open or use-by dates. The DM stated that all opened bread items should have an open or use-by date and that all products should be labeled and dated for storage. The facility's policies on receiving and food storage require that all food items be appropriately labeled and dated, and that food and drink items be discarded prior to expiration or within acceptable time frames for opened items.
Incomplete Medical Records for Resident Transfer
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident who was reviewed for discharge. The resident, who had a history of schizophrenia and other medical conditions, experienced a decline in health, prompting a recommendation for hospital evaluation. However, the medical record lacked documentation related to the discharge to the hospital, including the transfer form, physician order, change in condition, and notification to the responsible party. Interviews with staff revealed that there was confusion and uncertainty regarding the completion and documentation of the transfer process. A nurse stated that they did not see any documentation regarding the transfer in the electronic medical record. The Director of Nursing acknowledged the issue and mentioned efforts to locate the missing paperwork. A progress note was later entered as a late entry, detailing the steps taken during the transfer, but the original documentation was still missing. Further investigation showed that the nurse responsible for the transfer was confident that they completed the necessary paperwork, including the EMS and AHCA packets. However, the transfer form was not found in the system, and the Regional DON confirmed that while the form was started, it was unclear what happened to it. The facility's policy on transfer and discharge documentation was not adhered to, resulting in incomplete medical records for the resident.
Infection Control Deficiencies in Hand Hygiene and Equipment Storage
Penalty
Summary
The facility failed to ensure proper hand hygiene practices during medication administration, as observed with a Licensed Practical Nurse (LPN) who did not perform hand hygiene before or after administering medications to residents. The LPN was observed preparing and administering medications to two residents without using hand sanitizer or washing hands, both before entering and after exiting the residents' rooms. The LPN admitted to forgetting the hand hygiene protocol and was unaware of the necessity to perform hand hygiene at each step of the medication administration process. The Director of Nursing (DON) confirmed that the facility's policy requires hand hygiene before entering and after exiting a resident's room, as well as the use of gloves when handling medications. Additionally, the facility did not ensure the proper storage of reusable medical equipment, specifically a nebulizer, in a resident's room. The nebulizer was repeatedly observed on the bedside table with attached tubing and a face mask that was not covered or dated. The resident mentioned that the nebulizer was provided for a cough, which had since improved, but was instructed to keep it for use as needed. The DON stated that the tubing should be changed weekly, dated, and the face mask should be stored in a bag when not in use. These observations indicate a failure to adhere to infection prevention and control protocols, potentially increasing the risk of infection spread within the facility.
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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