Vero Beach Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Vero Beach, Florida.
- Location
- 1310 37th St, Vero Beach, Florida 32960
- CMS Provider Number
- 105474
- Inspections on file
- 38
- Latest survey
- May 20, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Vero Beach Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
A resident was found self-administering multiple supplements stored at their bedside without an assessment or care plan by the interdisciplinary team, as required by facility policy. The DON confirmed the lack of assessment and documentation for self-administration, despite the resident's ongoing use of these supplements and the facility's awareness of the situation.
A resident who was cognitively intact and required assistance with ADLs did not consistently receive showers as preferred, despite an updated shower schedule and previous grievances. Documentation showed missed or undocumented showers, and there was no evidence of resident refusal as required by policy, resulting in a failure to honor the resident's right to self-determination regarding bathing.
The facility failed to ensure timely skin assessments and medication administration for multiple residents. One resident with complex medical needs reported new skin issues that were not documented or communicated to the physician. Another resident experienced delays in receiving medications, missed showers, and unmet personal care preferences, with an LPN pre-signing medications before administration. A third resident reported ongoing late medication administration, with both morning and afternoon doses given hours after the scheduled time. These deficiencies occurred despite facility policy requiring medications to be given within one hour of the prescribed time.
A resident was found to have multiple bottles of pills and liquid supplements, such as MCT oil and testosterone boosters, stored unsecured on a bedside nightstand. The resident reported daily use and self-storage of these items, and the DON confirmed there was no assessment for self-administration and that bedside storage was not permitted.
A resident with cerebral palsy and contractures was found to have an unassessed wound on the right foot during a surveyor's observation. The wound care nurse and other staff were unaware of the wound, and erroneous measurements were documented. The facility failed to identify the wound during a skin check assessment, leading to a deficiency in care.
The facility failed to prevent and manage pressure ulcers for two residents. One resident experienced inadequate wound care due to improper procedures and lack of pain assessment, while another developed pressure wounds due to insufficient preventative measures and documentation. The staff did not adhere to care plans or implement necessary interventions to prevent and treat pressure ulcers effectively.
The facility failed to prevent and properly assess pressure ulcers for two residents. One resident developed ulcers on the heels due to a lack of preventative measures, and the treatment was delayed. Another resident had an unassessed ulcer on the right foot, which was only discovered during a surveyor's visit. The facility did not follow proper procedures, resulting in inadequate care and documentation.
The facility was found deficient in maintaining a clean and homelike environment, with issues such as sharp hooks, debris accumulation, and disrepair in multiple rooms. The Maintenance Director acknowledged these concerns during an environmental tour.
The facility failed to provide sufficient staffing, resulting in multiple falls, persistent odors, and inadequate personal care. Residents and families reported significant delays in call light responses, especially during night shifts. An LPN confirmed staffing shortages, leading to unattended treatments and compromised resident safety.
The facility failed to maintain food safety and sanitation standards, with issues such as unsecured sinks, improperly stored utensils, peeling paint, and debris on kitchen equipment. Raw beef was stored above tuna salad, and a dietary aide improperly dried trays. These deficiencies were acknowledged by the dietary management staff.
A facility failed to report a rash outbreak, potentially scabies, to the Florida DOH and did not ensure all affected residents received proper treatment. Additionally, a CNA did not follow Enhanced Barrier Precautions for a resident with an indwelling urinary catheter, indicating a lack of adherence to infection control protocols.
The facility failed to maintain a safe and sanitary environment in common areas across four units, with issues such as dust and mold-like substances in air vents, water damage, and debris accumulation. The Maintenance Director acknowledged these concerns during an environmental tour.
A resident with Chronic Systolic Congestive Heart Failure and Severe Morbid Obesity was unable to obtain a recliner to elevate his legs, despite repeated requests and medical necessity. The facility did not provide a recliner, expecting the resident to purchase one himself, which he could not do due to financial constraints. A temporary solution was found when a staff member provided a torn recliner from the maintenance area, leading to an improvement in the resident's condition.
Residents in the facility expressed ongoing dissatisfaction with the food quality, describing it as repetitive and poorly cooked. Despite repeated complaints to the Dietary Manager and Activities Director, these grievances were not adequately documented or resolved. The disconnect between resident feedback and staff response highlights a deficiency in the facility's grievance resolution process.
A resident with severe cognitive impairment and a history of falls was found to be restrained by a seatbelt in a companion chair, contrary to the facility's restraint-free policy. Despite the facility's policy, the seatbelt was used, and the resident was unable to remove it independently. Family members expressed concerns about safety and staffing, and staff confirmed the unauthorized use of the restraint, which was provided by Hospice services.
The facility failed to accurately assess two residents, one with visual impairment and another regarding antianxiety medication use. A resident, legally blind, was documented as having adequate vision in MDS assessments, while another was incorrectly recorded as receiving antianxiety medication without supporting MAR evidence. These inaccuracies were confirmed through staff interviews and record reviews.
The facility failed to develop and implement adequate care plans for two residents, one with a catheter and another with vision impairment. A resident with severe cognitive impairment was observed with an improperly placed catheter bag, and the care plan did not address his behavior of manipulating the catheter. Another resident, who is legally blind, had a care plan inaccurately reflecting his vision status, which was only revised after surveyor observation. These deficiencies highlight the facility's failure to maintain accurate and comprehensive care plans.
The facility failed to update care plans for two residents, one with aggressive behavior and another with a discontinued fluid restriction. Despite discussions, the care plan for a resident involved in altercations lacked documentation of aggression. Another resident's care plan inaccurately included a fluid restriction order that was no longer in place. The DON was unable to explain these discrepancies.
A resident with medically complex conditions and an ADL self-care deficit was left in wet adult depends after a CNA refused to change her, citing it was only urine. The resident, who was cognitively intact and expressed feelings of depression, required substantial assistance with toileting and hygiene. Despite requesting to be changed and transferred back to her wheelchair, the CNA left her in bed, highlighting a deficiency in meeting the resident's care needs.
The facility failed to coordinate hospice care and services for two residents, resulting in undocumented hospice and oxygen orders for one resident and lack of an offloading boot and hospice documentation for another. Staff interviews revealed a lack of awareness and communication regarding necessary care and equipment.
A resident with a history of falls experienced multiple incidents without adequate updates to their care plan or supervision. Despite several falls resulting in injuries, the facility's IDT often failed to implement new interventions. Interviews revealed concerns about inadequate staffing in the memory care unit, contributing to the inability to prevent falls effectively.
The facility failed to secure medication storage on two units, leaving medication and treatment carts unlocked and unattended. On the memory care unit, an LPN left a medication cart unsecured for over two hours, with cognitively impaired residents present. In another instance, a medication cart was found unattended with unsecured ointments, and a treatment cart was left unlocked in a common area with residents present.
The facility failed to maintain complete medical records for three residents, resulting in missing documentation of podiatry services, orthopedic follow-up, and psychological notes. A resident reported not seeing a podiatrist, and another had no record of an orthopedic follow-up. Additionally, a resident with behavioral issues had no psychological notes since the previous year. Staff interviews revealed lapses in communication and documentation processes.
The facility failed to properly explain arbitration agreements to two residents with intact cognition, resulting in signatures being obtained without understanding. The new Admissions Director, who was untrained, did not use the electronic signature process or provide copies of the agreements. The facility's records inaccurately reflected agreement to arbitration.
The facility failed to maintain a functioning call system for a resident and did not ensure the call light was accessible for another. A resident with intact cognition was unable to signal for help due to a non-functioning call system, confirmed by an LPN. Another resident could not reach the call light as it was improperly placed, with the cord wrapped around the bedrail and the button under the bed, as noted by the Environmental Services Director.
The facility did not ensure timely posting of nurse staffing information on four out of five days during a survey. The required information was not posted in the lobby area as expected, and there was confusion among staff about who was responsible for this task. The Administrator indicated that the night supervisor and receptionist were responsible, but this was not clearly communicated.
The facility failed to maintain a clean and safe environment, with issues such as torn wheelchair armrests, dirty floors, and unclean toilets. Residents reported longstanding cleanliness problems, including a pill on the floor for a month and dirty windows. Despite claims of cleaning, the surveyor found persistent issues, which the Housekeeping Supervisor acknowledged but could not explain.
A facility failed to follow physician orders for blood pressure medication and wound vac care for two residents. Medications were administered despite low systolic blood pressure, and wound vac care was not documented or consistently provided due to staffing issues and lack of training. The DON confirmed the deficiencies.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Assess and Plan for Resident Self-Administration of Medication
Penalty
Summary
A resident was observed with approximately ten bottles of pills and liquid supplements stored openly on their nightstand, including MCT oil, Nugenix Thermo X, weight loss probiotics, veggie capsules, testosterone boosters, and fruit dietary supplements. The bottles were open, and the resident reported self-administering these supplements daily due to dissatisfaction with the facility's food and a personal goal to lose weight. During the observation, the resident informed the LPN about the supplements after receiving their scheduled medication from the nurse. Interviews with facility staff, including the Director of Nursing, confirmed that the resident had not been assessed by the interdisciplinary team for self-administration of medication, nor was there a care plan in place for this practice. Review of the clinical record showed no documentation of such an assessment or care plan, despite facility policy requiring physician and care team approval for residents to self-administer medications. The facility was aware that residents were not permitted to store medications at their bedside without proper assessment and planning.
Failure to Honor Resident's Bathing Preferences and Support Self-Determination
Penalty
Summary
A deficiency was identified when a resident's right to self-determination and choice regarding bathing preferences was not honored. The resident, who is cognitively intact with a BIMS score of 15, reported not receiving a shower for approximately three weeks, despite expressing a preference for showers over bed baths. The resident also stated that his requests for specific types of incontinence briefs and linen changes were not consistently met, and that his leaking toilet had not been addressed. Staff interviews confirmed that the resident required assistance with activities of daily living (ADLs) and that there were inconsistencies in providing showers according to the resident's preferences and the facility's updated shower schedule. Review of facility documentation, including the resident's care plan, Kardex, and ADL task sheets, revealed that the resident was scheduled to receive showers on Monday, Wednesday, and Friday during the 7AM-3PM shift. However, records for April and May showed multiple instances where showers were not documented, and the resident often received sponge baths or full baths instead. There was also a lack of documentation indicating that the resident refused showers, as required by facility policy. The grievance log and Resident Council minutes indicated that the resident had previously raised concerns about not receiving showers as preferred, and the issue was marked as resolved after the shower schedule was updated, but subsequent documentation did not support consistent implementation of this schedule. Facility policy requires that all residents be offered and provided a shower unless they specifically request a bed bath, and any refusal must be documented with appropriate notifications. In this case, the lack of consistent documentation and failure to provide showers as scheduled demonstrated that the facility did not fully support or facilitate the resident's right to choose their preferred method of bathing, resulting in a deficiency.
Failure to Ensure Timely Skin Assessments and Medication Administration
Penalty
Summary
The facility failed to provide necessary care and services related to timely skin assessments and medication administration for several residents. One resident, with a history of diabetes, cerebrovascular disease, chronic kidney disease, hypertension, and blindness in one eye, reported new, painful, and itchy skin lesions to the surveyor. Upon assessment, the LPN stated a dermatology consult would be obtained, but there was no documentation of the new skin issues, no evidence of physician notification, and no new treatment orders in the clinical record. The DON later confirmed that new skin issues should be documented and that an order for cortisone was obtained only after the surveyor's inquiry. Another resident expressed dissatisfaction with care, stating that medications had not been received, showers had been missed for weeks, linens were not changed, and personal preferences for incontinence products were not honored. The DON initially reported that medications had been administered, but the nurse was later observed preparing and administering the resident's medications, which had already been signed off as given in the electronic record. The nurse admitted to pre-pouring medications, signing them off before administration, and delaying medication administration due to taking a lunch break, with morning medications not completed until late morning or noon. A third resident, who had resigned as Resident Council President due to ongoing unresolved issues, reported persistent delays in medication administration, including a specific incident where morning medications were not received until after noon. The resident also noted that afternoon medications were given in the evening. The nurse confirmed that medication passes for the hall were routinely not completed until late morning or noon. The DON acknowledged the resident's complaint but had not initiated a grievance or addressed the ongoing late medication administration concerns. Facility policy requires medications to be administered within one hour of the prescribed time, which was not consistently followed.
Unsecured Storage of Medications and Supplements at Bedside
Penalty
Summary
Surveyors observed that a resident had approximately ten bottles of pills and liquid supplements, including MCT oil, Nugenix Thermo X, weight loss probiotics, veggie capsules, testosterone boosters, and fruit dietary supplements, stored unsecured on top of the bedside nightstand. These items were clearly visible upon entering the resident's side of the room. During interviews, the resident confirmed daily use of these supplements and acknowledged storing them on the nightstand. The DON confirmed that the resident had not been assessed for self-administration of medication and was aware that medications were not to be stored at the bedside.
Failure to Identify and Assess Resident's Wound
Penalty
Summary
The facility failed to provide necessary care and services to prevent, identify, and properly assess wounds for a resident with a history of cerebral palsy, malnutrition, and contractures. The deficiency was identified when a surveyor observed a wound care nurse performing treatment on the resident's left foot but failing to inspect the right foot, where an open wound was later discovered. The wound care nurse was unaware of the wound on the right foot, and erroneous measurements were documented once the wound was identified. Interviews with staff revealed a lack of awareness and documentation regarding the resident's right foot wound. A Certified Nursing Assistant (CNA) and a Registered Nurse (RN) assigned to the resident were both unaware of the wound, and the RN had failed to identify it during a skin check assessment conducted the day before the surveyor's observation. The facility's Director of Nursing (DON) confirmed that a facility-wide skin sweep had been conducted, but the wound on the resident's right foot was still not identified. The wound care provider later assessed the wound as a trauma wound, noting it required surgical debridement and specific treatments. The provider suggested the wound could have been caused by friction or trauma, possibly due to the resident's limited mobility and contractures. The investigation concluded that the facility failed to identify and properly assess the wound prior to surveyor intervention, leading to the deficiency.
Plan Of Correction
F684, Quality of Care (1) What corrective action(s) will be accomplished for those residents who found to have been affected by the deficient practice? On resident #3 was immediately assessed by a licensed nurse for any adverse effects related to the alleged deficient practice, none were noted. The Attending Physician and care ARNP were immediately notified, orders for treatment received and treatment initiated on. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken. A quality review of current residents' skin was completed by the nurse practitioner/designee to ensure no new skin were noted and required treatment. Any issues identified were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur. The Assistant Director of Nursing or designee-initiated education for the current licensed nurses on about Comprehensive Skin Assessment and Areas to monitor on the body that are Susceptible to. Newly hired nurses will receive education by the Assistant Director of Nursing or designee related to the following: about Comprehensive Skin Assessment and Areas to Monitor on the Body that are Susceptible to. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Assistant Director of Nursing/Designee to conduct weekly audits of resident's Skin Assessments 2x weekly for 8 weeks, then 1x weekly for 4 weeks, and then random audits x 1 week for 4 weeks to ensure compliance with Care identification and appropriate treatments provided. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until substantial compliance has been met.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary care and services to prevent and promote healing of pressure ulcers for two residents. For Resident #3, the Wound Care Nurse (WCN) did not follow proper procedures during wound care, including failing to perform hand hygiene after removing a dirty dressing and before cleansing the wound. The resident, who has cerebral palsy, malnutrition, and contractures, expressed pain during the procedure, indicating a lack of assessment of the resident's tolerance to the treatment. The care plan for Resident #3 included specific interventions for skin checks and the use of supportive devices, but these were not adequately followed during the observed wound care session. For Resident #1, the facility did not implement preventative measures to minimize the development of pressure wounds. The resident was admitted for rehabilitation after a cervical fracture and initially had intact skin with no pressure wounds. However, the resident developed pressure wounds on the heels, which were not documented or staged in a timely manner. The WCN noted that the resident preferred to stay on their back due to a cervical collar, but there was no documentation of refusal to offload the heels or use preventative measures like offloading boots or skin prep before the wounds developed. The investigation revealed that the facility's staff were aware of the residents' conditions and preferences but failed to take appropriate actions to prevent and manage pressure ulcers. The lack of documentation and adherence to care plans contributed to the development and inadequate treatment of pressure wounds in both residents.
Plan Of Correction
F686, Treatment/Svc to prevent/ heal 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1, no longer resides in the facility, discharged on. Resident #3 was immediately assessed by a licensed nurse for any adverse effects related to the alleged deficient practice; none were noted. The Attending Physician and care ARNP were immediately notified, orders for treatment received, and treatment initiated on. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; A quality review of current residents' skin was completed by the nurse practitioner/designee on to ensure no new skin issues were noted and required treatment. Any issues identified were immediately corrected. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not reoccur. The Assistant Director of Nursing/designee initiated education on the components of the Failure to provide necessary care and services to prevent and promote healing, with emphasis on providing treatment to ensure the healing of. Newly hired nurses will be educated on the components of Failure to provide necessary care and services to prevent and promote healing, with emphasis on providing treatment to ensure the healing of by the Assistant Director of Nursing/designee at orientation as part of the systematic changes. 4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place. The Assistant Director of Nursing/designee will conduct random audits of 5 residents to ensure that their treatment and services have been provided according to their Physician Orders, 2x a week for 4 weeks, then 1x a week for 4 weeks, and then monthly for 1 month to ensure compliance. The findings of these quality monitoring will be reported to the Quality Assurance/Performance Improvement Committee monthly until substantial compliance has been met. F 686
Failure to Prevent and Assess Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary care and services to prevent, identify, and properly assess skin conditions for two residents. For Resident #1, the facility did not implement preventative measures to minimize the development of pressure ulcers. The staff were aware that the resident preferred to stay in a certain position due to a device in use, but there was no documentation of the resident's refusal to offload his heels. The treatment to mitigate the pressure ulcers, including the use of skin prep, was initiated only after the first ulcer developed. For Resident #3, the facility failed to identify and properly assess a pressure ulcer on the resident's right foot prior to surveyor intervention. The wound care nurse (WCN) did not perform hygiene after removing a dirty dressing and before applying treatment, and the resident's tolerance to the treatment was not acknowledged. The WCN also failed to inspect the right foot, where an open wound was later discovered by the surveyor. The nurse had no knowledge of the wound, and the facility's documentation did not accurately reflect the resident's condition. The facility's failure to follow policies and procedures during treatment administration and to conduct thorough skin assessments resulted in the oversight of existing wounds. The Director of Nursing (DON) confirmed that a facility-wide skin sweep was conducted, but the right foot wound was still missed. The investigation determined that the facility did not adequately assess and document the residents' skin conditions, leading to deficiencies in care.
Plan Of Correction
N201: Right to Adequate and Appropriate Healthcare. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1, no longer resides in the facility, discharged on. Resident #3 was immediately assessed by a licensed nurse for any adverse effects related to the alleged deficient practice; none were noted. The Attending Physician and care ARNP were immediately notified, orders for treatment received, and treatment initiated on. An order effective was created to provide off-loading; treatment to Resident #3. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Licensed Nursing staff will conduct weekly skin audits to monitor the residents for change in skin condition. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not reoccur. On, the Assisted Director of Nursing/designee initiated education on the components of the Failure to provide necessary care and services to prevent and promote healing of, with emphasis on providing treatment to ensure the healing of the. 4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Assistant Director of Nursing/designee will conduct random audits of 5 residents with to ensure that their treatment and services have been provided according to their Physician Orders, 2x a week for 4 weeks, then 1x a week for 4 weeks, and then monthly for 1 month to ensure compliance. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until substantial compliance has been met.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment across multiple units and common areas, as observed during an environmental tour with the Maintenance Director. Specific deficiencies included sharp picture hanging hooks protruding from walls, accumulation of residue and debris on air conditioning units, and multiple instances of disrepair such as damaged walls, missing closet doors, unsecured outlets, and worn furniture. Additionally, there were several instances of uncleanliness, including stained privacy curtains, dirty floors, and stained bed linens. The tour also revealed issues such as mold-like substances on bathroom caulking, unsecured baseboards, and damaged blinds. The Maintenance Director acknowledged understanding of these concerns during the tour. These observations indicate a failure to provide adequate maintenance and housekeeping services, compromising the residents' right to a safe and comfortable living environment.
Staffing Deficiencies Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing, as evidenced by multiple incidents and complaints across various units. On one unit, a resident experienced eleven falls, and the facility did not follow its fall prevention policy. Additionally, a persistent stale urine odor was noted throughout the unit during the survey, indicating a lack of adequate cleaning and care. Another resident did not receive personal care or assistance out of bed when requested, highlighting a failure in providing necessary activities of daily living (ADL) care. The facility also failed to coordinate hospice care for two residents, as there was no evidence of care coordination, order implementation, or hospice documentation. Numerous residents and family members voiced complaints about delayed responses to call lights, with some residents waiting up to two hours for assistance. These delays were particularly problematic during the night shift, where residents reported issues such as double diapering and missed personal care. The Resident Council minutes also reflected ongoing concerns about delayed call light responses. Staff interviews further confirmed the staffing inadequacies, with an LPN acknowledging insufficient staffing on a memory care unit. This lack of staffing led to situations where residents were left unattended during treatments, such as a nebulizer treatment. The overall findings indicate a systemic issue with staffing levels, impacting the quality of care and safety of residents in the facility.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain food safety and sanitation standards during a kitchen inspection. Observations revealed several deficiencies, including unsecured hand washing sinks and baseboards, improperly stored utensils, and peeling floor paint. There was also an accumulation of debris on kitchen equipment such as the can opener and slicer, and damaged shelving and rusted areas were noted. Additionally, the air conditioning vents were dusty, and the oven mitts were torn and uncleanable. In the walk-in cooler, raw beef was improperly stored above prepared tuna salad, and the cooler door was damaged. Cleaned hotel pans were found stacked while still wet, and the hand sink near the ice machine was not functional. The floor throughout the food service area was also damaged. During a follow-up kitchen tour, a dietary aide was observed using a paper towel to dry trays before meals were placed on them, which were then transported to the units. This practice was acknowledged by the Dietary Manager, the Regional Certified Dietary Manager, and the dietary aide as a concern. These observations indicate a failure to adhere to professional standards for food safety and sanitation, as acknowledged by the facility's dietary management staff.
Infection Control Deficiencies in Rash Outbreak and EBP Implementation
Penalty
Summary
The facility failed to adhere to infection control standards during a rash outbreak on one of its units, affecting multiple residents. The outbreak, which involved symptoms consistent with scabies, was not reported to the Florida Department of Health (DOH) as required. Several residents were administered Ivermectin for dermatitis or scabies, but not all received the recommended second dose, and some roommates were not treated prophylactically. The Physician Assistant who ordered the medication was unaware that some residents did not receive the second dose and did not recall the specifics of the rashes treated. The Director of Nursing (DON) did not report the outbreak to the DOH, claiming unawareness of the requirement. Additionally, the facility did not follow its Enhanced Barrier Precautions (EBP) policy for a resident with an indwelling urinary catheter. During an observation, a Certified Nursing Assistant (CNA) failed to don a gown while providing personal and catheter care, despite the policy requiring gowns and gloves for such procedures. The CNA admitted to not being informed about the necessity of wearing a gown, indicating a lack of proper training or communication regarding EBP protocols. The report highlights deficiencies in both the management of a potential scabies outbreak and the implementation of EBP for infection control. The facility's failure to report the outbreak and ensure proper treatment and precautions for affected residents demonstrates a significant lapse in infection prevention and control measures.
Environmental Deficiencies in Common Areas
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for residents, staff, and the public in the common areas across four of its five units. Observations revealed an accumulation of dust and mold-like substances in the air conditioning vents and ducts in multiple units, including the common and dining areas. Additionally, the shower room on the Canterbury unit had a large puddle of water on the floor, a running toilet, and damaged walls, while the soiled utility room had a damaged wall and a sink filled with standing dirty water. Further deficiencies were noted in the employee bathroom of one unit, where the wall and baseboard were damaged, and the wall at the handwashing sink was unfinished. The patio area had debris in the air conditioning vents, and the nurse's station restroom had an unsecured sink and a hole in the wall. Other issues included broken and oxidizing sink handles, holes in the walls around the nurse's station, and debris accumulation in pantries. The Maintenance Director acknowledged these concerns during an environmental tour.
Failure to Provide Recliner for Resident's Medical Needs
Penalty
Summary
The facility failed to honor a resident's choice to sleep in and utilize a reclining chair, which was necessary for his medical condition. The resident, who had multiple diagnoses including Chronic Systolic Congestive Heart Failure and Severe Morbid Obesity, required leg elevation to manage his symptoms. Despite his intact cognition, as indicated by a BIMS score of 15, the resident's repeated requests for a recliner were not fulfilled by the facility. The resident had been advised by his physician to elevate his legs as much as possible, yet he was unable to do so due to the lack of a recliner, which he had been trying to obtain since his admission. The resident's care plan documented his preference for a recliner to assist with sleeping and mobility, but the facility did not provide one. Interviews with the Director of Nursing and the Administrator revealed that the facility did not have recliners available and expected the resident to purchase one himself. The resident faced difficulties in purchasing a recliner due to financial constraints and the store's payment requirements, which he could not meet. Despite the resident's efforts to work with social services and the facility's administration, no recliner was provided until a staff member found a temporary solution by bringing a torn leather reclining chair from the maintenance area. The facility's inaction persisted despite the resident's clear communication of his needs and the medical necessity for a recliner. The Social Service Director and the Rehab Director both indicated that it was not their responsibility to provide a recliner, and the Administrator did not take steps to ensure the resident was placed on a waitlist for a rental chair. The lack of coordination and support from the facility staff resulted in a delay in meeting the resident's needs, which was only partially addressed when a temporary chair was provided, leading to an improvement in the resident's condition once he was able to elevate his legs.
Failure to Address Resident Food Quality Complaints
Penalty
Summary
The facility failed to promptly address and resolve grievances related to food quality voiced by residents and the Resident Council. Multiple residents, including those with high cognitive function scores, expressed dissatisfaction with the food served, describing it as repetitive, poorly cooked, and unappetizing. These concerns were consistently reported to the Dietary Manager and the Activities Director, yet no effective action was taken to resolve the issues. Interviews with residents revealed ongoing dissatisfaction with the meals provided, with descriptions of the food being institutional, tasteless, and sometimes inedible. Residents reported that they often had to rely on food brought in by family members or purchased outside the facility. Despite these complaints being voiced repeatedly, there was a lack of documentation in the Resident Council and Food Committee meeting minutes, indicating a failure to formally acknowledge and address the grievances. The Activities Director and Dietary Manager were aware of the complaints but did not document them adequately or take substantial steps to improve the situation. The Dietary Manager acknowledged receiving feedback during meetings but claimed that residents did not bring up significant issues. This disconnect between resident feedback and staff response highlights a deficiency in the facility's grievance resolution process, particularly concerning food quality concerns.
Unauthorized Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #128, was free from the use of physical restraints, which is a violation of their policy and regulatory requirements. The resident, who was admitted to the facility and later to Hospice services, had a history of falls and was severely cognitively impaired, requiring substantial assistance for mobility. Despite the facility's policy against restraints, a seatbelt was observed attached to the resident's companion chair, which the resident could not remove independently, effectively acting as a restraint. Observations and interviews revealed that the seatbelt was used on multiple occasions, despite the facility's restraint-free policy. The resident's son and daughter expressed concerns about the resident's safety due to frequent falls and the perceived lack of adequate staffing in the memory care unit. The daughter acknowledged the regulations regarding restraints but was unsure about the origin of the chair with the seatbelt. Staff interviews confirmed that the seatbelt was not supposed to be used, but it was observed in use during a surveyor's visit, and the resident was unable to stand due to the restraint. Further investigation revealed that the companion chair with the seatbelt was provided by Hospice services upon the resident's admission to their care. Staff members, including a Licensed Practical Nurse and a Hospice Registered Nurse, confirmed the use of the seatbelt and acknowledged that the resident could not unclip it independently. The facility's Director of Nursing confirmed the delivery of the chair, but there was no documented assessment or care plan addressing the use of the seatbelt, highlighting a failure in adhering to the facility's policy and ensuring the resident's freedom from unauthorized restraints.
Inaccurate Resident Assessments for Vision and Medication
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care. Resident #48, who was admitted with conditions including heart failure, hypertension, diabetes mellitus, and major depressive disorder, was inaccurately assessed regarding his visual impairment. Despite being legally blind, as confirmed by both the resident and staff, the Minimum Data Set (MDS) assessments consistently documented his vision as adequate. Interviews with staff revealed a lack of awareness and proper documentation of the resident's visual impairment, which was only corrected after the surveyor's review. Resident #60, admitted with a diagnosis of depression, was inaccurately documented in the MDS assessment as receiving antianxiety medication, despite the medication administration records for July and August showing no such orders. This discrepancy was confirmed during an interview with the MDS Director, highlighting a failure in accurately recording the resident's medication regimen.
Inadequate Care Plans for Residents with Catheter and Vision Impairment
Penalty
Summary
The facility failed to develop and implement adequate care plans for two residents, leading to deficiencies in their care. Resident #91, who has severe cognitive impairment and multiple medical diagnoses, was observed with an improperly placed catheter bag that was not draining correctly. Despite having a care plan for catheter use, the plan did not address the resident's behavior of manipulating the catheter, which was only added after the surveyor's observation. Staff interviews revealed that the issue was known but not documented in the care plan until the surveyor's intervention. Resident #48, who is legally blind, had a care plan that inaccurately reflected his vision status. The care plan initially documented his vision as adequate, despite the resident and staff acknowledging his blindness. The care plan was only revised to reflect his severe vision impairment after the surveyor's observation. Interviews with staff indicated a lack of awareness of the resident's true vision status, leading to inadequate interventions for his condition. These deficiencies highlight the facility's failure to maintain accurate and comprehensive care plans that address the specific needs and conditions of the residents. The lack of timely updates and accurate documentation in the care plans resulted in inadequate care and oversight for the residents involved.
Failure to Revise Care Plans for Aggression and Fluid Restriction
Penalty
Summary
The facility failed to revise care plans for two residents, leading to deficiencies in addressing their specific needs. Resident #81, who was admitted to the facility and had been involved in two resident-to-resident altercations, did not have any documentation related to physical aggression or conflicts in their care plan. Despite discussions in a morning meeting about adding this information, it was not included, and the Director of Nursing (DON) was surprised by the omission. The Social Services Director (SSD) indicated that the Minimum Data Set (MDS) staff were expected to update the care plans, but this was not done. Resident #79, diagnosed with End Stage Renal Disease and previously on a fluid restriction, had a care plan that inaccurately documented a fluid restriction order that had been discontinued. The care plan, which had been revised multiple times, still included the outdated fluid restriction information. The DON was informed of this discrepancy but could not provide an explanation or further information by the time of the survey exit conference.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for a resident who required substantial assistance due to medically complex conditions. The resident, who was cognitively intact, expressed feelings of depression and had an ADL self-care deficit related to cellulitis. The resident was occasionally incontinent of urine and frequently incontinent of bowel, necessitating regular assistance with toileting and hygiene. On a specific day, the resident reported having a bowel movement and being changed by a CNA, but later wet her adult depends and requested assistance to be changed again. The CNA dismissed the request, stating it was only urine, and left the resident in wet depends until the next shift arrived. Interviews with staff revealed that the resident had requested to use the bathroom and be transferred back to her wheelchair, but the CNA refused, citing difficulty in performing the task. The resident was left in bed to watch TV without being changed or transferred as requested. The social service director was informed of the resident's concerns regarding the lack of care and services provided. This incident highlights a deficiency in the facility's ability to meet the resident's needs for personal hygiene and mobility assistance, as outlined in her care plan.
Coordination of Hospice Care and Equipment Deficiencies
Penalty
Summary
The facility failed to ensure proper coordination of care and services for two residents receiving hospice care. For one resident, there was a lack of documented orders for hospice services and oxygen use, despite the resident being admitted to hospice care and receiving oxygen for comfort. Observations revealed the resident was on oxygen without any formal order, and staff were unaware of the existing orders or the resident's oxygen use history. The Unit Manager confirmed the resident was on hospice services but could not locate any orders for hospice or oxygen. For the second resident, there was a failure to coordinate the provision of an offloading boot, and the facility lacked the Certificate of Terminal Illness paperwork and current hospice notes. The resident, who had a terminal illness and pressure ulcers, was observed without proper offloading of the foot, which was directly on the mattress or pillow. The Wound Care Nurse and CNA were unsure about the presence or use of an offloading boot, and there was no order for such a boot, despite documentation indicating its necessity. Interviews with staff revealed a lack of communication and follow-up regarding the hospice services and necessary equipment for the residents. The Wound Care Nurse acknowledged the absence of a pressure-relieving boot and stated that hospice would assess the need for one. The Director of Nursing agreed that there were no hospice notes since the resident's admission, indicating a significant gap in documentation and coordination of care.
Failure to Prevent Falls and Update Care Plan for Resident
Penalty
Summary
The facility failed to adhere to its fall prevention policy for Resident #128, who had a history of falls and was at risk for further incidents. Despite multiple falls occurring over several months, the facility did not consistently update the resident's care plan with new interventions or adequately supervise the resident to prevent further falls. The resident experienced numerous falls, some resulting in injuries, yet the care plan often lacked new or effective interventions to address the recurring issue. Resident #128 was admitted with a known history of falls and was assessed as being at risk for falls. The resident experienced several falls, including incidents where she was found on the floor in other residents' rooms, tripped over a floor mat, and fell after a door was opened. Despite these incidents, the facility's interdisciplinary team (IDT) often failed to implement new interventions or update the care plan appropriately. For example, after a fall on 03/30/24, the IDT did not add any new interventions, and similar inaction was noted after subsequent falls. Interviews with the resident's family and staff highlighted concerns about inadequate staffing and supervision, particularly in the memory care unit where Resident #128 resided. The resident's daughter expressed frustration over the repeated falls and the perceived lack of staff to provide necessary supervision. Staff interviews revealed that the unit was often understaffed, with insufficient CNAs to meet the needs of residents with cognitive impairments, which contributed to the inability to prevent falls effectively.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to secure medication storage on two of its five units, as observed by surveyors. On the designated memory care unit, a medication cart was left unlocked and unattended in the common area, with bubble pack medication cards visible on top. Staff K, an LPN, was observed working at a desk on the other side of the common area and later assisting a resident with lunch, leaving the cart unsecured for over two hours. During this time, cognitively impaired residents were present in the area, and Staff K was unaware that both the medication and treatment carts were unlocked. In another instance, a medication cart was found unattended between rooms, with unsecured tubes of Zinc Oxide in a bin on the side. Additionally, a treatment cart was observed unlocked and unattended in the common area, with nine cognitively impaired residents present. Staff K, LPN, stated she had not used the treatment cart that day and was unaware it was unlocked. These observations indicate a failure to adhere to protocols for securing medication and treatment carts, posing potential risks to residents.
Incomplete Medical Records and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain complete and current medical records for three residents, leading to deficiencies in documentation and care coordination. Resident #5, who was admitted to the facility, reported not having seen a podiatrist despite having thick elongated toenails. The electronic medical record lacked any documentation of podiatry services, and the Social Services Director (SSD) was unable to provide evidence of such services. Additionally, the SSD admitted to not having seen any psychologist notes and had not taken action to address the absence of consultant progress notes in the medical records. Resident #26 had an order for a follow-up appointment with an orthopedic physician, but the record lacked evidence of the appointment or any reason for its absence. The Director of Nursing (DON) could not provide documentation related to the follow-up. Resident #81, who was being monitored for behaviors and had two altercations since admission, had no psychological notes since 2023. Staff interviews revealed that the psychologist's notes were supposed to be sent via email to Medical Records, but this was not occurring routinely, leading to incomplete documentation in the resident's medical records.
Failure to Properly Explain and Document Arbitration Agreements
Penalty
Summary
The facility failed to ensure that the arbitration agreement was explained to residents or their representatives in a manner they understood, and did not obtain proper signatures from residents who agreed to the arbitration agreement. This deficiency was identified for two residents, both of whom had intact cognition as indicated by their BIMS scores of 15/15. During interviews, both residents confirmed that they were asked to sign documents related to arbitration but were not given explanations about what they were signing. Additionally, they did not receive copies of the arbitration agreements, and their signatures were not obtained electronically as required. The issue arose due to a lack of proper training and communication among the facility staff. The Marketing Director and Administrator acknowledged that the new Admissions Director, who had not yet been trained, was responsible for obtaining the signatures. The Admissions Director admitted to not using the electronic signature process and not providing copies of the agreements to the residents. The facility's list of residents who agreed to arbitration was also inaccurate, as it did not reflect the absence of electronic signatures on the agreements.
Deficiencies in Call System Accessibility
Penalty
Summary
The facility failed to maintain a functioning call system for one resident and failed to ensure the call light was accessible for another resident. Resident #27, who was cognitively intact with a BIMS score of 13, was unable to signal for assistance as the call system did not function. During an interview, the resident attempted to use the call light, but there was no indication at the nurse's station or over the door that the call had been initiated. This issue was confirmed by a Licensed Practical Nurse who was present at the time. Additionally, Resident #95, also cognitively intact with a BIMS score of 13, was unable to reach the call light due to its improper placement. The call light cord was tightly wrapped around the bedrail, and the button was positioned underneath the bed, making it inaccessible to the resident. The Environmental Services Director was informed of the issue and struggled to untangle the cord, highlighting the inaccessibility of the call light for the resident.
Failure to Timely Post Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the timely posting of nurse staffing information on four out of five days during the survey period. On 09/09/24, upon entrance at 8:40 AM, the nurse staffing information, which should include the number of Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants along with their actual hours worked, was not posted in the lobby area. A subsequent walk-through at 9:09 AM confirmed the absence of this information in the lobby and all units in the main building. On the following days, the nurse staffing information for 09/09/24, 09/10/24, and 09/11/24 was found on the receptionist's desk in the lobby, but not posted as required. During an interview on 09/13/24, the Administrator stated that the responsibility for posting the nurse staffing information at the beginning of each shift lay with the night supervisor and the receptionist. However, the staff at the receptionist desk was unsure of who was responsible, indicating a lack of clarity and communication regarding this duty.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for its residents, as observed during two separate tours conducted with the Maintenance Director and Housekeeping Manager. Several deficiencies were noted, including torn wheelchair armrests, dirty floors with debris, and unclean toilets. Residents reported longstanding issues, such as a pill on the floor that had been there for a month and dirty windows and blinds. Additionally, a large brown stain was observed on a mattress, and a used COVID test was found on a windowsill. The caulking around a toilet was discolored and cracked, and a door in the Rehab Unit was difficult to open. Interviews with residents and the Housekeeping Supervisor revealed that cleaning was inadequate, with reports of only garbage cans being emptied and floors remaining dirty. Despite claims from the Housekeeping Supervisor that cleaning had been performed, the surveyor found that the pill remained on the floor, the toilet was unclean, and the floor was still dirty. The Housekeeping Supervisor acknowledged these findings but was unable to explain why the cleaning was not completed as expected.
Failure to Follow Physician Orders for Medication and Wound Care
Penalty
Summary
The facility failed to ensure that nursing staff adhered to physician orders for administering blood pressure medication to a resident with a history of hypertension, orthostatic hypotension, atrial fibrillation, and falls. The physician's orders specified that Diltiazem and Metoprolol should be withheld if the resident's systolic blood pressure (SBP) was below 105 or heart rate (HR) was below 60. Despite these instructions, the medications were administered on multiple occasions when the resident's SBP was below the specified threshold. The Director of Nursing confirmed that the medications should have been held according to the orders. Additionally, the facility did not follow physician orders for the application and maintenance of a wound vac for another resident who had been hospitalized for an infected sacral ulcer resulting in sepsis. The orders required the wound vac to be applied and changed three times a week, but there was no documentation indicating that this care was provided. Interviews with nursing staff revealed a lack of clarity and training regarding responsibility for wound vac care, especially in the absence of the designated wound care nurse. The facility's documentation and staffing practices contributed to the deficiencies. The wound care nurse was unavailable during a critical period, and there was no replacement or clear delegation of responsibilities to other nursing staff. Interviews with various staff members highlighted inconsistencies in understanding and executing wound care duties, with some staff expressing a need for additional training. The Director of Nursing was unable to provide documentation confirming that the wound vac orders were followed, indicating a lapse in adherence to prescribed care protocols.
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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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