Vivo Healthcare Gandy
Inspection history, citations, penalties and survey trends for this long-term care facility in Tampa, Florida.
- Location
- 4610 S Manhattan Ave, Tampa, Florida 33611
- CMS Provider Number
- 105491
- Inspections on file
- 29
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at Vivo Healthcare Gandy during CMS and state inspections, most recent first.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Facility administration failed to ensure that an allegation of neglect involving a medically complex resident left unattended on a smoking patio for over 4.5 hours was promptly investigated, documented, and reported. Security footage reportedly showed the resident receiving no care from the assigned CNA during this period, after which the resident was found unresponsive and a code blue was initiated. The incident was not entered into the abuse log, and key staff, including an RN unit manager, therapy staff, and department heads, denied knowledge of the event or provided vague responses during a complaint survey. Despite policies requiring immediate reporting and investigation of suspected violations, the administration did not effectively implement these processes, and leadership later acknowledged that information about the incident and related concerns had been hidden.
Surveyors found that during an influenza outbreak, staff wore masks in resident care areas but visitors were not notified of the outbreak, were not offered masks, and saw no posted signage in the lobby or elsewhere about the situation or recommended PPE, despite facility policies requiring visitor education, isolation signs, and passive screening through posted notices. Additionally, uncovered nebulizer masks were observed left out on furniture in two resident rooms on separate units, contrary to the facility’s oxygen administration policy requiring delivery devices to be kept covered when not in use.
A resident with intact cognition and multiple medical conditions reported ongoing language barriers, including staff pushing phones with translator apps toward residents and speaking Spanish while caring for English‑speaking residents. Multiple grievances and resident council reports over several months documented that CNAs on one station spoke little or no English, that residents were uncomfortable with staff using phones to translate, and that staff spoke Spanish to each other during mealtimes in front of English‑speaking residents, with items repeatedly marked as unresolved and lacking documented follow‑up. Surveyors were unable to interview a CNA due to a language barrier, and an LPN/unit manager acknowledged that CNAs had difficulty understanding clinical questions and that resident council raised language concerns monthly. The Social Services Director and Social Worker confirmed ongoing grievances related to language barriers, reliance on verbal reminders, prohibition on translator use, and lack of documented grievance resolutions, despite facility policies requiring culturally competent care, effective communication in a language residents can understand, and adequate staff guidance and training.
The facility failed to follow its abuse and neglect policy and federal timeframes for reporting and investigating multiple allegations involving several residents. One resident with extensive terminal and respiratory diagnoses was reportedly left on an unsupervised smoking patio for over 4.5 hours without care before being found unresponsive and coded, yet this event was not entered in the abuse log or treated as a neglect allegation by the NHA, DON, or an LPN supervisor. Another resident with hemiplegia reported to psychology that a named individual repeatedly entered his room at dusk, touched him in a way he described as violating and demeaning, while the NHA described a similar allegation of being slapped and acknowledged reporting it to state agencies the next day, outside the required 2-hour window. A third resident with hemiplegia alleged that a female staff member refused to provide a call light or incontinence care during the night shift; documentation showed only one change early in the evening, and the NHA treated this as neglect without physical injury and reported it to the state more than 24 hours after notification, despite policy defining abuse to include deprivation of services. A fourth resident with dementia and muscle wasting reported that three people were in her room, with one female hitting her, and a family member alleged she was beaten by staff; the NHA acknowledged that notifications to state agencies occurred more than two hours after the allegation, again outside policy requirements.
The facility failed to promptly and thoroughly investigate and report several alleged abuse and neglect incidents. One resident with multiple terminal diagnoses was left on an unsupervised smoking patio for hours without documented care and was later found unresponsive, yet leadership did not treat this as a neglect allegation or initiate an investigation at the time. Another resident with hemiplegia reported a male staff member repeatedly entering his room at dusk and touching him in a way he described as violating and demeaning, but the allegation was not reported within the required 2-hour timeframe. A third resident with hemiplegia reported that a female staff member refused to provide incontinence care or give her a call light, and a fourth resident with diabetes alleged abuse related to how medications and care were provided; in both cases, the NHA minimized the allegations, misapplied the facility’s abuse definition, and delayed or limited reporting and investigative actions.
The facility did not maintain a clean and sanitary condition in a community shower room on Unit 4. Observations showed black substances on shower curtains, caked substances on the floor, and yellow liquid on the toilet rim. The shower stalls had missing tiles and uncleanable areas, while the sink and shower bed had rust and dried substances. Interviews revealed a lack of routine checks and cleaning, with the Housekeeping Director and RN/UM acknowledging the issues. The Maintenance Director was unaware of the poor condition until the survey.
The facility failed to refer residents with diagnosed or suspected mental illness for Level II PASRR evaluations. Residents with significant mental health diagnoses, such as schizophrenia and bipolar disorder, were not properly assessed, leading to a lack of appropriate mental health services. Interviews with staff revealed a lack of understanding in the PASRR process.
The facility failed to implement care plans for residents, leading to deficiencies in care. A resident on fluid restriction had unauthorized access to fluids, another self-administered oxygen without proper orders, a third lacked a documented discharge plan, and a fall-risk resident had incomplete safety interventions. Staff interviews revealed gaps in communication and enforcement of care plans.
A resident with a recent amputation and other medical conditions did not receive wound care as prescribed. The dressing on the resident's right ankle was undated, and staff could not confirm when it was last changed, despite documentation indicating daily changes were required. The Director of Nursing acknowledged that dressings should be dated.
A resident with a PICC line for IV antibiotics had a dressing that was not fully attached, and the facility failed to document the catheter length and arm circumference as required. The resident's medical records showed inconsistencies in documenting the condition of the IV site and completion of treatments. Staff interviews revealed a lack of adherence to the facility's policy on PICC line management.
A facility failed to ensure effective communication with a Dialysis center for a resident with ESRD. The Dialysis staff did not provide or document post weights, vital signs, or treatment details across fourteen visits. The resident confirmed the lack of documentation in the communication book. Facility staff verified that the Dialysis center often returned forms blank, leaving them without crucial information. Despite attempts to resolve the issue, the facility only received the necessary documentation when the State was present.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with MRSA, as staff did not use proper PPE during high-contact care activities. The resident had a surgical incision and was colonized with a multidrug-resistant organism, requiring EBP according to the facility's policy. Interviews with staff revealed a lack of understanding and adherence to EBP guidelines.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
Failure to Investigate and Report Alleged Neglect of Resident Left Unattended on Smoking Patio
Penalty
Summary
Facility administration failed to utilize resources effectively to ensure allegations of abuse and neglect were thoroughly investigated and reported in a timely manner for multiple residents. The Nursing Home Administrator’s job description required directing day-to-day functions in accordance with federal, state, and local regulations to assure quality care, including reviewing resident complaints and grievances, maintaining written records of complaints, and reporting all allegations of resident abuse and misappropriation of property. The DON’s job description outlined responsibilities for ensuring quality and safe delivery of nursing services, accurate and timely documentation, continuous observation and monitoring of seriously ill residents, and acting as a patient advocate. Despite these defined roles and responsibilities, the facility did not ensure that an allegation of neglect involving a resident on the smoking patio was properly investigated, documented, or reported. Resident #3 was admitted with serious medical conditions including metabolic encephalopathy, major depressive disorder, antineoplastic chemotherapy, secondary malignant neoplasm of the lung, malignant neoplasm of the brain, severe calorie malnutrition, cachexia, COPD, personal history of pneumonia, and acute respiratory failure with hypoxia. A witness statement dated on a specified date described security camera footage from the smoking patio showing this resident, who was assigned to a specific CNA for care, entering the smoking patio in the afternoon and remaining there without any visits or care from the assigned CNA. The statement indicated that at 5 p.m. the resident was found unresponsive by other staff, assisted indoors, and a code blue was called, with the video showing that the resident received no care of any kind from the assigned CNA for over 4.5 hours. Review of the facility’s abuse log for the relevant period showed that this incident was not listed, indicating it was not entered into the abuse/neglect tracking system. During a complaint survey, interviews with key personnel who were employed at the time of the incident revealed they were not willing or able to participate meaningfully in the survey process regarding the investigation of abuse and neglect. The RN Unit Manager, Director of Rehabilitation, Housekeeping Manager, Assistant DON, two Social Services Directors, and therapy staff denied knowledge of the resident having been left unattended for 4.5 hours, or that the resident coded, required CPR for more than 10 minutes, and subsequently expired. Their responses included statements such as not remembering the incident, not being told anything by administration, not knowing, not feeling comfortable answering, or lacking specifics. At the time of the investigation, it was unclear whether these key staff had not participated in any investigation of this traumatic event or were not forthcoming, which impacted the survey process. Review of the facility’s Compliance and Ethics Reporting policy showed that employees were required to report suspected violations immediately and that all reports were to be investigated and tracked for QAPI, but the handling of this incident and the absence of the event from the abuse log demonstrated that these reporting and investigation processes were not effectively implemented by facility administration. Further, interviews with the RDCS and the facility’s CNO revealed that they only became aware of the witness statement about the resident being left outside for 4.5 hours shortly before the survey interview and that the allegation of neglect had only then been reported. They stated that the LPN who wrote the witness statement had focused on the caregiver rather than the resident and that the LPN had not reviewed the full 4.5 hours of video. The RDCS stated that administration was not forthcoming and that there had been an unsupervised smoking patio at the time of the incident. The CNO reported discovering that the NHA had a culture of hiding information and that the NHA had concealed matters from them. These statements, combined with the lack of timely reporting, incomplete or absent investigation, and failure to document the incident in the abuse log, demonstrate that facility administration did not administer the facility in a manner that ensured effective use of resources to investigate and report allegations of abuse and neglect as required by policy and job responsibilities.
Failure to Notify Visitors of Influenza Outbreak and Properly Store Nebulizer Masks
Penalty
Summary
The facility failed to consistently implement its infection prevention and control program during an influenza outbreak and in the handling of nebulizer equipment. During an initial tour, surveyors observed that all staff in resident care areas were wearing masks and staff reported this was required due to a flu outbreak that began several days earlier, with 21 residents testing positive. However, in the lobby there was no signage notifying visitors of the outbreak or recommending PPE such as masks, and the receptionist did not provide any information or instructions about the outbreak. Two family members who visited residents on multiple occasions reported they had not been notified of the flu outbreak, had not been offered masks, and only became aware of the situation by seeing staff wearing masks. The Infection Preventionist later confirmed that while resident representatives were notified of the outbreak by telephone, the facility did not encourage mask use for visitors and did not post signage to notify visitors or recommend/encourage mask use, contrary to the facility’s infection control policy requiring visitor education, use of isolation signs, and passive screening via posted signs. Surveyors also observed improper storage of nebulizer masks on two units. On the 300 unit, an uncovered nebulizer mask was seen on a resident’s dresser in front of the television, and on the 100 unit, another uncovered nebulizer mask was observed on a circular table in a resident’s room. Photographic evidence was obtained. The Infection Preventionist, upon reviewing the photos, stated that nebulizer items should be stored in a bag and that all nurses had been instructed on this practice. This practice was inconsistent with the facility’s written policy on oxygen administration, which requires delivery devices to be kept covered when not in use, and with the infection prevention and control policy that all staff follow procedures designed to prevent the development and transmission of communicable diseases and infections.
Failure to Address Repeated Grievances About Language Barriers and Ineffective Communication
Penalty
Summary
The deficiency involves the facility’s failure to provide staff with adequate training and effective processes to address language barriers that had been repeatedly reported through grievances and resident council meetings. A cognitively intact resident with a Brief Interview for Mental Status (BIMS) score of 15 reported that language remained a significant barrier and that the resident council had been discussing this issue for months without resolution. This resident stated that staff would push their phones toward residents and attempt to use translator applications for communication, which the resident refused, believing they should be able to communicate with staff directly without a translator. The resident also reported hearing staff speak Spanish while caring for other residents who only spoke English. Review of grievance records showed multiple complaints over several months related to staff not speaking or understanding English and staff speaking Spanish in front of non‑Spanish‑speaking residents, particularly on one unit. One grievance described a CNA who could not answer a resident’s question because she could not speak English and did not understand what the resident was asking, with no resolution documented. Another grievance from a resident and family member reported difficulty communicating with a specific care staff member due to a language barrier and poor response time; the only documented action was that the employee was counseled, with no follow‑up recorded. Resident council grievances repeatedly documented that CNAs on a particular station did not speak or knew very little English, that residents felt uncomfortable with staff using phones to translate, and that staff spoke Spanish to each other during mealtimes in front of English‑speaking residents. These items were repeatedly marked as “Not Resolved – Action Needed,” and residents noted that prior nursing grievances had not been resolved and that they wanted action taken. Surveyor interviews further demonstrated ongoing communication problems and lack of effective staff training. An attempted interview with a CNA could not be completed because the CNA did not understand questions asked in English, evidencing a direct language barrier between staff and surveyors. A unit manager LPN stated that communication with staff on one unit was easier for her because she could use “Spanglish,” and acknowledged that CNAs on that unit had difficulty understanding clinical questions unless speech was slow and clear; she also confirmed that resident council repeatedly raised concerns about staff speaking Spanish in the hallways and that staff used translator applications on their phones to communicate with residents and English‑speaking staff. The Social Services Director acknowledged grievances related to language barriers and stated that staff had only been given verbal reminders not to speak other languages while caring for residents, which had not been effective. The Social Worker reported a potential issue with Spanish‑speaking staff and residents, stated that staff were not allowed to use translators to communicate with residents, and that being able to communicate and read English was a requirement for staff, but also stated that resolutions to grievances were not specifically documented. The Regional Director of Operations stated that the facility needed to go beyond verbal communication to resolve a repeating issue and that more should have been done to provide staff with resources and residents with communication in a language they understand, while facility policies required culturally competent care, effective communication in a language residents can understand, and sufficient guidance and training for staff on communication, which were not effectively implemented.
Failure to Timely Report and Investigate Multiple Abuse and Neglect Allegations
Penalty
Summary
The deficiency involves the facility’s failure to timely report and investigate multiple allegations and indications of abuse and neglect in accordance with its own Abuse, Neglect and Exploitation policy and federal reporting timeframes. The policy required all alleged violations to be reported to the Administrator, state agency, adult protective services, and other required agencies immediately but not later than 2 hours if the events involved abuse or resulted in serious bodily injury, and not later than 24 hours if the events did not involve abuse and did not result in serious bodily injury. The policy also defined an "alleged violation" as any situation or occurrence observed or reported that, if verified, could indicate noncompliance with federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property. Despite this, the facility did not treat several events as reportable allegations and did not report them within the required timeframes. For one resident with multiple serious diagnoses including metabolic encephalopathy, major depressive disorder, metastatic cancer to the lung and brain, severe calorie malnutrition, cachexia, COPD, history of pneumonia, and acute respiratory failure with hypoxia, a written witness statement described security camera footage showing the resident entering the smoking patio in the afternoon and remaining there for the entire afternoon without any visits or care from staff or the assigned CNA. The statement indicated that at 5 p.m. the resident was found unresponsive by another staff member, brought indoors, and a code blue was called, and that the resident did not receive care from the assigned CNA for over 4.5 hours. This statement was signed and dated by an LPN. The incident did not appear on the facility’s abuse logs, and the NHA, DON, and an LPN supervisor each stated they did not investigate or report the event as an allegation of neglect or a reportable event, citing reasons such as viewing it as a "regular code," believing the resident’s terminal diagnoses and poor prognosis made the death unsurprising, and stating there was no supervision of the patio at that time. The LPN who wrote the statement later said the statement about the resident remaining unattended for 4.5 hours was false and that her focus was on the CNA’s performance, but also stated that administration was aware of the statement and did not report or investigate it. For another resident with hemiplegia and hemiparesis, a psychology progress note documented that the resident, who was alert and oriented, reported that a person identified by name came to his room at dusk, patted him on the head, pinched his cheek, and made a familiarizing comment, which the resident described as violating his space and demeaning. The NHA stated that the resident had alleged that a short-haired man slapped him and that he reported this to a nurse two days prior, and that the resident had a similar prior allegation. The NHA reported that the incident was assessed with no injuries and that she did not have a name to go by, and she did not identify the named individual from the psychology note as part of the investigation. She acknowledged that she reported the incident to DCF and AHCA the day after the event and that this did not meet the facility’s policy requirement to report within two hours. For a third resident with hemiplegia and hemiparesis, the abuse log showed an incident in which the resident reported that a female staff member entered her room during the night shift, refused to give her the call light, stated she was not the resident’s assigned CNA and that the resident did not have a CNA, and then left without changing the resident despite the resident’s stated need. The NHA stated that when she reviewed the chart, she saw documentation of the resident being changed only once at 8:17 p.m. and that the assigned CNA reported being with another resident and eventually returning, but there was no exact time. The NHA said the resident had glaucoma and could not clearly identify the staff member, and that the resident later told psych it was probably a misunderstanding and denied being abused. The NHA stated she treated this as a neglect incident, not abuse, because there was no physical injury, and reported the incident to AHCA more than 24 hours after she was notified, despite acknowledging that abuse allegations should be reported within two hours and that the policy defined abuse to include deprivation of goods or services. For a fourth resident with muscle wasting and atrophy, cognitive communication deficit, and unspecified dementia, the abuse log and psychology note documented that the resident reported three people (one male and two females) in her room, with the male asleep in her bed and one female hitting her, then feeding others before all left. The NHA stated that a family member alleged the resident was beaten up by staff and that she was notified when the incident happened. She reported that she notified DCF and AHCA more than two hours after the allegation, explaining that she was with the police and unable to report sooner. The NHA acknowledged that reporting of abuse incidents should occur within two hours. The Regional Director of Clinical Services confirmed that there were no reports filed or investigations conducted for the resident who died on the patio and stated that the NHA should have filed reports within the required timeframes and that another staff member could have submitted reports if the NHA was unavailable.
Failure to Timely Investigate and Report Multiple Abuse and Neglect Allegations
Penalty
Summary
The deficiency involves the facility’s failure to promptly and thoroughly investigate multiple allegations of abuse and neglect, and to treat certain events as reportable alleged violations in accordance with its own abuse, neglect, and exploitation policy. The policy required immediate investigation when suspicion or reports of abuse, neglect, or exploitation occurred, including identifying responsible staff, interviewing all involved persons, and providing complete documentation. Despite this, the facility did not initiate an investigation or log an allegation related to a resident who was observed on security camera footage remaining on the smoking patio for approximately 4.5 hours without care from his assigned CNA and who was later found unresponsive at 5 p.m., after which a code blue was called. The Nursing Home Administrator (NHA), Director of Nursing (DON), and an evening supervisor each stated they did not view this sudden death as an allegation of neglect or a reportable event, and no investigation or abuse log entry was made at the time. The DON acknowledged there was no hydration cart and no supervision of the patio, and the evening supervisor confirmed there was no clear view of the resident while he was outside and that the incident was not witnessed by staff. The deficiency also includes delayed and incomplete responses to other abuse and neglect allegations. One resident with hemiplegia and hemiparesis reported that a male staff member, identified in a psychology note as a person named by the resident, came to his room at dusk, patted his head, pinched his cheek, and asked, "how is my guy today," which the resident described as violating his space and demeaning. The NHA later described a similar allegation as involving a short-haired man who allegedly slapped the resident, but stated the resident could not provide a name and that prior similar incidents were not substantiated. The NHA acknowledged that the abuse allegation was not reported within the two-hour timeframe required by policy, instead being reported the next day to state agencies. Another resident with hemiplegia and hemiparesis reported that during the night shift a female staff member entered her room, refused to give her the call light, stated she was not the assigned CNA and that the resident did not have a CNA, and left without providing requested incontinence care. The NHA stated that chart review showed only one documented change at 8:17 p.m. and that the assigned CNA reported being with another resident and eventually returning, but there was no exact time established. The NHA said she treated this as neglect rather than abuse because there was no physical injury, despite the facility policy defining abuse to include deprivation of goods or services. The NHA also stated she believed she had 24 hours to report if there was no injury, and confirmed that abuse allegations should actually be reported within two hours. A further allegation involved a resident with diabetes mellitus who reported being abused by staff because a nurse would not leave medications at the bedside and the resident refused care from her CNA that night. The NHA stated she did not consider this to be abuse, even though the resident alleged abuse, and that she found it odd but did not question the CNA further after the CNA reported that nothing had happened on her shift. The resident later accepted care and medication from another nurse, and the NHA reported the matter as neglect, not abuse. The NHA also stated that the resident refused to be interviewed by her on two occasions and that she did not know what the resident meant by being abused and never found out. Across these incidents, the Regional Director of Clinical Services confirmed that no reports were filed or investigated for the resident who died after being on the patio, and that the NHA failed to file required reports within policy timeframes, despite the job description requiring the NHA to operate the facility in accordance with federal, state, and local regulations and to review resident complaints and grievances with appropriate written follow-up.
Facility Fails to Maintain Sanitary Conditions in Shower Room
Penalty
Summary
The facility failed to maintain a clean and sanitary condition in one of the two community shower rooms located on Unit 4. Observations revealed multiple issues, including black substances on shower curtains, caked black substances on the floor around the toilet, and yellow liquid on the toilet rim. The shower stalls had yellow substances, missing tiles, and cement-like porous areas that were uncleanable. The wall vent fan was covered in dust, and the sink had rust-colored stains. Additionally, the shower bed and bedside commode were found with dried brown, black, and yellow substances. Interviews with the Housekeeping Director, RN/UM, and Maintenance Director highlighted a lack of routine checks and cleaning of the shower room and equipment. The Housekeeping Director expected daily cleaning, but the shower room was not appealing. The RN/UM admitted to not routinely checking the equipment, and the Maintenance Director was unaware of the poor condition until the survey. The facility's policy emphasized maintaining a sanitary environment, but the observed conditions did not align with these standards.
Failure to Conduct Level II PASRR for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that residents with diagnosed or suspected mental illness were referred to the State's Mental Health authority for a Level II Preadmission Screening and Resident Review (PASRR) for four residents out of 29 sampled. Resident #47 was admitted with multiple mental health diagnoses, including paranoid schizophrenia and major depressive disorder. Despite these diagnoses, the Level I PASRR screen indicated that a Level II evaluation was not required, which was a misjudgment given the resident's mental health conditions. Resident #79, who was admitted with undifferentiated schizophrenia, bipolar disorder, and major depressive disorder, also did not receive a Level II PASRR despite exhibiting behaviors such as hallucinations and yelling. The facility's Assistant Director of Nursing (ADON) and Social Services Director (SSD) acknowledged the resident's mental health issues and behaviors but did not initially pursue a Level II assessment. The resident's care plan and psychiatric notes indicated ongoing mental health challenges that warranted further evaluation. Similarly, Resident #19 and Resident #73 were admitted with significant mental health diagnoses, including bipolar disorder, depression, and anxiety, yet their Level I PASRR screenings did not lead to Level II evaluations. Both residents had documented histories of mental health issues that caused functional impairments, but the facility's assessments failed to recognize the need for further evaluation. Interviews with facility staff revealed a lack of understanding and coordination in the PASRR process, leading to these oversights.
Failure to Implement Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement care plan interventions for four residents, leading to deficiencies in their care. Resident #19, who was on a fluid restriction due to conditions such as hypo-osmolality and hyponatremia, was observed with a foam cup at her bedside, contrary to her care plan instructions. Interviews with staff revealed a lack of awareness about the resident's fluid restriction, indicating a failure to communicate and enforce the care plan effectively. Resident #24, diagnosed with COPD and chronic respiratory failure, was self-administering oxygen without a physician's order or a self-administration assessment. The care plan did not include provisions for self-administration of oxygen, and staff interviews confirmed that the resident was managing his oxygen use independently without proper authorization or documentation. Resident #32, who expressed a desire to transition to an Assisted Living Facility, did not have a discharge plan documented in his care plan, despite multiple discussions with the Social Services Director. Additionally, Resident #133, identified as a fall risk, had an incomplete baseline care plan with missing interventions to prevent falls. Observations showed the resident's call light was out of reach, and side rails were not positioned as required, further highlighting the facility's failure to implement necessary safety measures.
Failure to Provide Prescribed Wound Care
Penalty
Summary
The facility failed to provide wound care as prescribed for Resident #118, who was observed with an undated dressing on the right ankle. The resident, who had a left lower extremity amputation and other medical conditions such as osteomyelitis and a local skin infection, was supposed to have the dressing changed three times a week. However, the dressing was not dated, and the staff could not confirm when it was last changed, although it was documented as completed on a previous Saturday. The Treatment Administration Record (TAR) for January 2025 indicated that the dressing change was to be performed daily, involving cleansing the surgical site, applying betadine, and covering it with gauze and an elastic wrap. Despite this, the dressing was not dated, and the Director of Nursing confirmed that dressings should be dated when changed. This oversight in documentation and adherence to the prescribed wound care regimen led to the deficiency identified by the surveyors.
Deficiency in PICC Line Management
Penalty
Summary
The facility failed to maintain the intravenous (IV) access of a resident in accordance with professional standards. The resident, who had a peripherally inserted central catheter (PICC) in the right upper arm, was observed with a dressing that was not fully attached to the skin. The dressing was dated several days prior, and the resident reported having an infection in the spinal cord. The resident's medical records indicated a diagnosis of bacteremia and pseudomonas infection, requiring IV antibiotics. The facility's documentation revealed several deficiencies in the management of the resident's PICC line. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed inconsistencies and omissions in documenting the measurement of the external catheter length and arm circumference, as required by the facility's policy. Despite orders to measure the arm circumference and catheter length with each dressing change, the records lacked these measurements on multiple occasions. Additionally, the documentation did not consistently reflect the condition of the IV site or the completion of scheduled treatments. Interviews with staff members, including a Registered Nurse (RN), Unit Manager (UM), and Director of Nursing (DON), highlighted a lack of adherence to the facility's policy regarding PICC line management. Staff acknowledged the failure to document the catheter length and the incorrect entry of orders that did not prompt the necessary documentation. The facility's policy required weekly dressing changes and documentation of the catheter length to prevent infection and ensure proper catheter placement, but these procedures were not consistently followed.
Failure in Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure effective communication with the Dialysis center providing treatment services for a resident with end-stage renal disease. The deficiency was identified through observations, interviews, and record reviews, revealing that the Dialysis nursing staff did not collaborate with the nursing facility by failing to provide and document post weights, vital signs, Dialysis vascular access site status, and details of the Dialysis treatment provided. This lack of documentation was consistent across fourteen Dialysis service visits. The resident involved was alert and able to discuss his medical care, confirming that he attended a Dialysis center three times a week. He mentioned that a yellow book was supposed to be filled out by the Dialysis center staff with his medical information, but he could not recall the last time it was completed. The facility's Licensed Practical Nurse verified that the communication sheets from the Dialysis center often returned blank, leaving the nursing facility staff without crucial information about the resident's medical and vital status during Dialysis sessions. Interviews with facility staff, including the Unit Manager and the Nursing Home Administrator, confirmed ongoing issues with the Dialysis center's refusal to fill out the necessary communication forms. Despite attempts to resolve the issue through communication with the Dialysis center, the facility did not receive the required information until the State was present in the nursing home, prompting the Dialysis staff to fax the necessary documentation. The facility's policy and the coordination agreement with the Dialysis center outlined the expectations for communication and collaboration, which were not met in this case.
Failure to Implement Enhanced Barrier Precautions for Resident with MRSA
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) and proper use of Personal Protective Equipment (PPE) for a resident diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) and other infections. On the morning of January 13, 2025, a resident was observed in their room without the required signage for EBP, despite having a surgical incision and being colonized with a multidrug-resistant organism (MDRO). Later that day, two Certified Nursing Assistants (CNAs) repositioned the resident without donning protective gowns, only wearing gloves, which was against the facility's policy for residents requiring EBP. The resident's medical history included a recent admission for orthopedic aftercare following a surgical amputation, sepsis due to MRSA, and other infections. The resident's care plan, updated on January 13, 2025, indicated the need for EBP due to the risk of infection from the MDRO. However, staff members were not fully aware of the resident's need for EBP, as evidenced by their failure to use the appropriate PPE during high-contact care activities. Interviews with staff, including a CNA, a Registered Nurse (RN), the Director of Nursing (DON), and the Assistant Director of Nursing/Infection Preventionist (ADON/IP), revealed a lack of consistent understanding and implementation of EBP. The DON and ADON/IP acknowledged that the resident should have been on EBP due to their MDRO diagnosis and the presence of a surgical incision. The facility's policy, revised in September 2022, clearly outlined the need for gowns and gloves during high-contact activities for residents with MDROs, but this was not followed in practice.
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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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