Sandgate Gardens Rehab And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Pierce, Florida.
- Location
- 703 S 29th St, Fort Pierce, Florida 34947
- CMS Provider Number
- 105382
- Inspections on file
- 28
- Latest survey
- November 3, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Sandgate Gardens Rehab And Nursing Center during CMS and state inspections, most recent first.
A resident with cognitive and physical impairments was not provided with the required two-person assistance or bilateral bedrails during incontinent care, resulting in a fall and minor injury. Documentation of the incident was incomplete, and staff interviews confirmed that established safety interventions were not followed.
The facility did not follow the planned menu for a lunch meal, affecting nearly all residents who eat orally. The kitchen staff substituted shredded cheese for the required cheese sauce and used chopped parsley instead of a parsley sprig for both regular and mechanically altered diets. For the pureed diet, the required cheese sauce and pureed bread were not prepared, and powdered parsley was omitted. Dietary staff confirmed these deviations, citing forgetfulness and resident preferences.
The facility did not ensure that meals for residents on pureed and mechanical soft diets were prepared to the required consistency, serving large pieces of meat and gritty pureed meat instead of the specified textures. Both the cook and CDM confirmed the food was not prepared according to dietary requirements, affecting several residents who rely on these specialized diets.
A resident who preferred watching TV in his room was unable to access several major channels, including CBS, NBC, and ABC, despite the facility's documentation stating these should be available. The resident reported the issue multiple times, but staff did not document or address the concern, and the Maintenance Director was unaware of the problem until informed by a surveyor. This resulted in the resident's choices not being respected.
Comprehensive assessments for four residents were not completed within the required 14-day admission or annual timeframes. One assessment was 15 days late, another was four days late, a third was nine days late, and one had not been completed as of the review. Staff interviews confirmed awareness of the required timelines, but no explanation was provided for the delays.
Quarterly assessments for three residents were not completed within the required timeframes, with several assessments finalized well after the regulatory deadlines. The MDS Coordinator and Regional MDS Director confirmed these delays during the survey.
Surveyors identified inaccurate MDS assessments for four residents, including incorrect coding for dialysis, antipsychotic medication, and hospice services. Documentation and interviews revealed that residents were not receiving the treatments or services recorded in their MDS, and staff acknowledged these discrepancies during record reviews.
A resident with limited English proficiency and moderate cognitive impairment did not receive appropriate communication support, such as interpreter services or alternative communication tools, despite documented needs. Staff failed to recognize the language barrier, resulting in the resident's ongoing pain not being properly assessed or addressed.
Three residents with severe cognitive impairment and ADL self-care deficits did not receive proper nail care, as evidenced by repeated observations of long, dirty, and unkempt fingernails. Staff interviews revealed confusion about who was responsible for nail care, with some CNAs believing they could not cut fingernails and others unsure of the policy, despite facility guidelines requiring such care for dependent residents.
Two residents did not receive appropriate care: one with a surgical wound was not provided with a required offloading device despite documented need and staff awareness, and another received antihypertensive medication outside of physician-ordered blood pressure parameters, as confirmed by the DON.
A resident with a UTI had a lab result indicating resistance to Cipro, but the result was not reviewed or acted upon promptly. Cipro was ordered and administered despite the resistance, and there was no documentation of the UTI or antibiotic use in the progress notes. The resident was later hospitalized for sepsis related to the untreated infection and returned with orders for IV antibiotics.
Multiple residents experienced inadequate pain management due to failures in pain identification, lack of medication availability, unclear medication indications, and inconsistent pain assessments. One resident's pain went untreated due to a language barrier and absence of pain medication orders, while another had interruptions in Oxycodone administration because the facility ran out of medication. A third resident received medication not clearly indicated for migraines, leading to confusion among staff, and a fourth resident did not receive consistent pain assessments before and after PRN pain medication.
The facility did not follow pharmacy recommendations for two residents, including not adhering to a recommended nicotine patch tapering schedule for one resident and failing to document the prescriber's rationale for disagreeing with a pharmacist's recommendation regarding Seroquel for another resident. In both cases, required documentation and communication were lacking.
Medications were found unsecured in two instances: a resident had a cup of pills, including Protonix and Amlodipine, left at their bedside, and a medication cart in Unit B was observed unlocked and unattended on two separate occasions. An LPN confirmed the presence of the pills, and the medication cart was accessible for several minutes without staff supervision.
Surveyors found that the facility did not consistently implement or document Enhanced Barrier Precautions and Contact Precautions for several residents with wounds or MDRO infections. Observations revealed missing PPE, absent precaution signage, and lack of physician orders for required precautions, despite care plans and diagnoses indicating the need for such measures. The Infection Preventionist confirmed these lapses during interviews.
A resident with endocarditis and multiple fractures did not receive IV antibiotics within the facility's required timeframe, as doses were frequently administered several hours late. The resident reported inconsistent timing, and MAR review confirmed repeated late administrations. The DON acknowledged these findings.
A resident with moderate cognitive impairment did not receive the pneumococcal vaccine despite having signed consent, due to conflicting documentation in the medical record and lack of follow-up by the Infection Preventionist to verify vaccination status.
The facility failed to provide timely and appropriate pressure ulcer care for three residents, leading to deficiencies in their treatment and care. A resident with a Stage III pressure ulcer did not receive prescribed wound care for 10 days due to a failure to input orders into the electronic medical record. Another resident did not receive weekly skin assessments, and a third resident had inconsistent documentation of wound care treatments. These issues highlight a pattern of inadequate documentation and follow-through in the facility's wound care practices.
Failure to Provide Required Supervision and Assistive Equipment During Care
Penalty
Summary
A deficiency occurred when a resident with significant cognitive and physical impairments, including hemiplegia, traumatic brain injury, aphasia, and a history of falls, was not provided with adequate supervision and assistive equipment during incontinent care. The resident's care plan and physician orders specified the need for two-person assistance for bed mobility and toileting, as well as the use of bilateral bedrails for safety. However, on the date of the incident, only one staff member assisted the resident, and the bed was not equipped with the required side rails. During care, the resident rolled off the bed and sustained a minor injury, with bleeding noted from the mouth. Documentation related to the incident was incomplete, lacking immediate witness statements and clear identification of the staff involved. Interviews confirmed that the staff member was alone during the incident and that side rails were not in place, contrary to the care plan and physician orders. The Director of Nursing and Administrator were made aware that established interventions for fall prevention and safe care were not followed at the time of the incident.
Failure to Follow Planned Menu for Lunch Meal
Penalty
Summary
The facility failed to follow the planned menu for one of two observed meals, specifically lunch, affecting 96 of 99 residents who consume food orally. Observations revealed that the regular and mechanically altered Philly Beef sandwiches were prepared with shredded cheese instead of the required cheese sauce, and finely chopped parsley was used instead of a parsley sprig. For the pureed diet, the cook did not prepare the required cheese sauce or pureed bread, and powdered parsley was omitted. During interviews, dietary staff acknowledged forgetting to make the pureed bread and stated that the cheese sauce was not prepared because residents did not like the canned version, and no attempt was made to obtain the cheese sauce mix as specified in the menu.
Failure to Provide Properly Prepared Pureed and Mechanical Soft Diets
Penalty
Summary
During a lunch meal observation, the facility failed to provide food in the appropriate form for residents requiring pureed and mechanical soft diets. The main entrée, a Philly Beef Sandwich, was not prepared according to the specified recipes for these diet types. The ground meat for the mechanical soft diet was supposed to be processed to a coarse consistency, but large pieces of meat were observed on the tray line. The pureed meat, intended for residents needing a smooth texture, was not processed to a fine consistency and was found to have a gritty texture upon tasting. Additionally, the sandwiches for both regular and mechanical soft diets were topped with shredded cheese and finely chopped parsley, which was not in accordance with the menu. Interviews with the cook and the Certified Dietary Manager (CDM) confirmed that the meat served did not meet the required consistency for either the mechanical soft or pureed diets. The cook acknowledged preparing the regular meat in a way that was not suitable for the mechanically altered meal, and the CDM agreed that the meat was not coarsely ground as required. Photographic evidence was obtained to support these findings. This deficiency affected multiple residents who required pureed and mechanical soft diets.
Failure to Honor Resident TV Channel Preferences
Penalty
Summary
A resident with a history of anxiety disorder and depression, who was cognitively intact and preferred to spend time reading and watching TV in his room, reported that his choice of television channels was not being honored. The resident expressed frustration that several major channels, including CBS, NBC, ABC, and WTCN, were unavailable on the facility's TV system, despite documentation indicating that 49 channels should be accessible. He specifically mentioned missing a desired program and stated that his concerns had not been addressed by staff, even after multiple complaints. Upon investigation, the Maintenance Director confirmed that the channels in question were not functioning and admitted she was previously unaware of the issue. The process for reporting such concerns required staff to document them in the TELLS system, but this had not occurred, resulting in the resident's ongoing dissatisfaction and lack of access to his preferred television programming. The deficiency was identified through observation, interview, and record review, demonstrating a failure to support and facilitate resident choice as required.
Failure to Complete Timely Comprehensive Assessments
Penalty
Summary
The facility failed to complete comprehensive assessments for residents within the required timeframes as specified by the Resident Assessment Instrument (RAI) guidelines. Specifically, four residents did not have their admission or annual comprehensive assessments completed within 14 days of admission or within the annual timeframe. One resident's assessment was completed 15 days late, another's annual assessment was completed four days late, a third resident's assessment was nine days late, and a fourth resident's assessment had not been completed as of the date of review. During interviews, the MDS Director confirmed the required timeframes for assessment completion, and the Regional MDS Director was unable to provide an explanation for the delays. These findings were based on record review and staff interviews, with no additional information provided regarding the residents' medical histories or conditions at the time of the deficiency.
Failure to Complete Timely Quarterly Resident Assessments
Penalty
Summary
The facility failed to complete quarterly assessments for three residents within the required timeframes as specified by the Resident Assessment Instrument (RAI) guidelines. Record reviews showed that multiple quarterly assessments for these residents were not completed within 92 calendar days after the previous assessment, nor within the 14-day window following the Assessment Reference Date (ARD). Specific instances included assessments for one resident with ARDs on 06/10/24, 09/10/24, and 03/11/25, which were completed significantly later than required. Similar delays were found for two other residents, with assessments completed past the regulatory deadlines. During an interview, both the MDS Coordinator and the Regional MDS Director acknowledged and agreed with these findings. No additional information about the residents' medical history or condition at the time of the deficiency was provided in the report.
Inaccurate MDS Assessments for Dialysis, Medication, and Hospice Coding
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for four residents, resulting in multiple instances of incorrect coding. For one resident, the admission MDS assessment inaccurately documented that the resident was receiving dialysis services, despite no evidence in the physician orders, progress notes, or resident interview to support this. Two other residents had MDS assessments that incorrectly indicated the administration of antipsychotic medications during the look-back period, although medication and treatment administration records did not show any such medications were given. In both cases, MDS coordinators acknowledged the discrepancies during side-by-side record reviews. Additionally, another resident's quarterly MDS assessment failed to indicate that hospice services were being provided, even though physician orders and progress notes confirmed hospice care had been initiated and was ongoing. The MDS coordinators also acknowledged this error during a review. These inaccuracies were identified through record reviews and staff interviews, with documentation and resident statements directly contradicting the information recorded in the MDS assessments.
Failure to Provide Communication Support for Non-English Speaking Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure effective communication with a resident who was unable to speak English. The facility's policy required providing appropriate support and assistance for communication, including the use of qualified interpreters and alternative communication tools for residents with language barriers. Despite documentation in the resident's care plan and admission records indicating a preference for Spanish and a need for an interpreter, staff did not provide these services. The resident, who had a history of COPD, was moderately cognitively impaired and was receiving hemodialysis. She had an active order for pain monitoring and a documented history of a right heel wound. Pain assessments recorded a pain level of zero, but during interviews conducted in Spanish, the resident reported severe, ongoing pain in her right heel and stated that she had repeatedly informed staff about her pain without any action being taken. She also reported that staff did not understand her due to the language barrier and that she was not offered a translator or communication tools, making it difficult to communicate her needs. Staff interviews revealed a lack of awareness regarding the resident's language needs, with both the DON and a CNA incorrectly believing the resident spoke English. No communication tools or language line services were used, despite their availability. The resident's representative also confirmed the absence of Spanish-speaking staff and expressed that having a translator would be beneficial. The facility's failure to provide appropriate communication support resulted in the resident's pain not being properly assessed or addressed.
Failure to Provide Nail Care for Residents Unable to Perform ADLs
Penalty
Summary
The facility failed to provide adequate nail care for three residents who were unable to perform activities of daily living (ADLs) independently, as observed and documented over several days. All three residents were severely cognitively impaired, with conditions such as dysphagia, aphasia, dementia, and senile degeneration of the brain, and had documented ADL self-care deficits in their care plans. Despite these documented needs, repeated observations revealed that each resident consistently had long, dirty, and unkempt fingernails. One resident also had chipped nail polish that was not addressed. Interviews with residents and their representatives indicated that nail care was often neglected unless specifically requested by family members. Staff interviews revealed confusion and inconsistency regarding responsibility for nail care. Certified Nursing Assistants (CNAs) reported being unsure whether they were permitted to cut fingernails, with some believing only a podiatrist could do so, while others stated they were only allowed to clean nails. The Unit Manager and an LPN clarified that CNAs were trained and expected to cut fingernails, with the exception of toenails, but acknowledged the confusion among staff. The facility's policy required appropriate ADL care, including nail care, for residents unable to perform these tasks independently, but this was not consistently implemented for the sampled residents.
Failure to Provide Offloading Device and Adhere to Antihypertensive Parameters
Penalty
Summary
The facility failed to provide appropriate care and services for two residents. For one resident with a surgical wound, documentation indicated the need for offloading the affected area using standard facility practices, such as a foam boot, to minimize pressure. Despite the resident's report of unintentionally rolling onto the wound during sleep and the nurse practitioner's verbal acknowledgment of a solution, no foam boot was provided, and staff were unaware of any such device being ordered or available. Observations confirmed the absence of the offloading device in the resident's room, and the wound care nurse stated that no order for the boot had been entered. For another resident with a history of orthostatic hypotension and multiple falls, the physician's order specified that Midodrine should be held if the resident's blood pressure exceeded 130. However, medication administration records showed that the antihypertensive was given on two occasions when the resident's blood pressure was above the prescribed threshold. The DON confirmed that the medication should have been withheld according to the order.
Failure to Timely Review Lab Results and Administer Appropriate Antibiotic for UTI
Penalty
Summary
A resident was admitted to the facility and had a urine sample collected for urinalysis, which later tested positive for a urinary tract infection (UTI). The urinalysis report, which indicated the presence of bacteria resistant to Cipro, was not signed off as reviewed by staff. Despite the resistance noted in the report, Cipro was ordered and administered to the resident five days after the urinalysis results were available. There was no documentation in the progress notes regarding the UTI diagnosis or the use of Cipro during this period. Subsequently, the resident developed a fever and decreased intake, leading to hospital admission where they were diagnosed with sepsis secondary to the UTI. Upon return to the facility, the resident had a care plan for sepsis with ESBL and E. coli bacteremia and was prescribed intravenous Ertapenem. Interviews with the Unit Manager and DON confirmed the urinalysis was not reviewed in a timely manner and that the antibiotic administered was not appropriate for the identified bacteria.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for four residents, as evidenced by multiple deficiencies in pain identification, medication availability, and assessment practices. One resident with a history of chronic obstructive pulmonary disease, arthritis, and a recent right heel wound reported severe pain for approximately two months, which was not addressed by staff due to a language barrier and lack of pain medication orders. Despite care plan interventions to monitor and manage pain, the resident's complaints were not understood or acted upon, and no pain assessments were conducted by nursing staff. Another resident with a right leg fracture experienced interruptions in pain medication administration due to the facility running out of Oxycodone on multiple occasions. The medication was not available for several scheduled doses, and delays in prescription refills and access to the emergency medication supply were documented. The nurse practitioner and DON were unaware of the medication availability issues until after the fact, and pharmacy communication lapses contributed to the delay in pain management. A third resident with moderate cognitive impairment and a history of neck and shoulder pain was prescribed Tizanidine for neck pain and muscle spasms, but the medication was not clearly indicated for migraine headaches, which the resident also experienced. Staff were unclear about which medication to administer for migraine complaints, leading to confusion and inadequate pain management. Additionally, a fourth resident with multiple fractures and endocarditis did not consistently receive pre- and post-administration pain assessments for PRN Oxycodone, and reported that staff were not always available to provide pain medication as needed. Documentation of pain assessments was lacking, and the resident stated that reassessment of pain after medication administration was rare.
Failure to Ensure Proper Drug Regimen Review and Documentation
Penalty
Summary
The facility failed to ensure appropriate drug regimen reviews for two residents. For one resident, the pharmacy recommended a specific tapering schedule for a nicotine patch, including a six-week period on a 14 mg dose before tapering to 7 mg, with clear stop dates. However, the resident was switched from 14 mg to 7 mg after only five days, rather than the recommended six weeks. The resident was not informed of this change, and the B-Unit Manager confirmed that nurse practitioners entered new orders after pharmacy recommendations, but she did not have access to the recommendations themselves. For another resident, the pharmacist recommended that the prescriber address the ongoing need for Seroquel, as there was no recent documentation of its necessity or the ability to taper the dose. The prescriber disagreed with the recommendation but did not provide a rationale on the Medication Regimen Review (MRR) form or in the medical record. The A-Unit Manager acknowledged that after discussing the case with the prescriber, she failed to document the reason for disagreement on the MRR form, despite signing it after the conversation.
Unsecured Medications and Unattended Medication Cart
Penalty
Summary
Surveyors observed that medications were not properly secured in the facility, resulting in two specific deficiencies. On one occasion, a cup containing two pills—identified as Protonix and Amlodipine—was found at the bedside of a resident, rather than being administered directly or stored securely. The resident had a history of gastroesophageal reflux disease and hypertension, as indicated by the medications present. A Licensed Practical Nurse confirmed the presence and identification of the pills. Additionally, on two separate occasions, a medication cart in Unit B was found unlocked and unattended in a hallway, with the drawers facing outward and accessible. The cart remained unattended for several minutes, and the responsible nurse was not present at the time of observation. These incidents demonstrate a failure to ensure that drugs and biologicals were stored in locked compartments and not left unsecured or accessible to residents.
Failure to Implement and Document Required Infection Control Precautions
Penalty
Summary
The facility failed to follow established infection prevention and control practices for residents requiring Enhanced Barrier Precautions (EBP) and Contact Precautions. For one resident with a wound, there was no EBP signage or Personal Protective Equipment (PPE) available in or outside the room during multiple observations, despite the resident having an active wound infection and orders for wound care. The Infection Preventionist confirmed that EBP orders and PPE should have been in place, but follow-up observations showed continued non-compliance. Additionally, three residents with documented infections requiring Contact Precautions did not have appropriate physician orders in place. One resident with an ESBL-positive wound had a Contact Precaution sign posted but lacked a corresponding order. Two other residents with ESBL E. coli bacteremia and MRSA infections had care plans indicating the need for transmission-based precautions, but no active Contact Precaution orders were found in their records. In one case, only an EBP sign was present when Contact Precautions were required. Interviews with the Infection Preventionist confirmed that the necessary orders and precautions were not implemented as required by facility policy. The deficiencies were identified through record reviews, direct observations, and staff interviews, highlighting lapses in the execution of infection control protocols for residents with wounds and multidrug-resistant organism (MDRO) infections.
Failure to Administer IV Antibiotics Timely
Penalty
Summary
The facility failed to administer intravenous (IV) antibiotics in a timely manner for a resident who was admitted with endocarditis and multiple fractures. According to the facility's policy, medications are to be administered within one hour before or after their prescribed time unless otherwise specified. The resident was prescribed ceftriaxone 2 grams IV every 12 hours for 38 days. Record review showed that the administration times for both morning and evening doses of ceftriaxone frequently fell outside the required one-hour window, with some doses being administered several hours late. The resident, who was cognitively intact, reported that the IV antibiotic was not given consistently every 12 hours and that the timing varied by several hours. Review of the Medication Administration Record (MAR) for the month revealed multiple instances where the 8 AM and 8 PM doses were administered late, sometimes by more than four hours. During an interview, the Director of Nursing acknowledged and agreed with these findings.
Failure to Administer Pneumococcal Vaccine Despite Signed Consent
Penalty
Summary
A deficiency occurred when the facility failed to provide the pneumococcal immunization to a resident who had signed consent for the vaccine. The facility's policy required assessment of vaccination status within five working days of admission and administration of the vaccine within thirty days unless medically contraindicated, already given, or refused. In this case, the resident had a re-entry admission and a documented moderate cognitive impairment, with a BIMS score of 12. The electronic medical record indicated that the resident refused the pneumococcal vaccine, but there was also an uploaded, signed informed consent for the vaccine dated the same day as admission. During interviews, the Infection Preventionist was unable to explain the discrepancy between the documented refusal and the signed consent. The Infection Preventionist later confirmed that the resident still wanted the vaccine but was unable to verify if the vaccine had been administered, citing lack of access to the Florida Shot Finders website. No follow-up was provided to the surveyor regarding the resident's vaccination status, resulting in a failure to ensure the resident received the pneumococcal immunization as per facility policy.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide timely and appropriate pressure ulcer care for three residents, leading to deficiencies in their treatment and care. Resident #1 was admitted with a Stage III pressure ulcer, but did not receive the prescribed wound care until 10 days after admission. The Wound Care Nurse failed to input the physician's orders into the electronic medical record, resulting in a delay in treatment. Additionally, weekly skin assessments were not consistently documented, with only one assessment noted after admission. Resident #2, who had multiple wounds on her left lower extremity, did not receive weekly skin assessments as required. The last documented assessment was on 11/28/24, and subsequent assessments were not completed. An observation revealed multiple bruises and a blood blister on the resident's right arm, which were not addressed in a timely manner. The nurse responsible for the resident confirmed the lack of completed assessments and attributed it to the resident's room location. Resident #3 had physician orders for wound care that were not consistently documented as completed. The Treatment Administration Record (TAR) showed missing initials for several dates, indicating that the prescribed treatments may not have been performed. The Wound Care Nurse admitted to sometimes failing to check the electronic medical record before performing treatments, leading to potential lapses in care. These deficiencies highlight a pattern of inadequate documentation and follow-through in the facility's wound care practices.
Latest citations in Florida
Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
