Vivo Healthcare Wauchula
Inspection history, citations, penalties and survey trends for this long-term care facility in Wauchula, Florida.
- Location
- 401 Orange Place, Wauchula, Florida 33873
- CMS Provider Number
- 105362
- Inspections on file
- 16
- Latest survey
- June 27, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Vivo Healthcare Wauchula during CMS and state inspections, most recent first.
The facility failed to maintain food safety standards, with issues such as disrepair in the storeroom floor, mold in refrigerators, improper food storage, and inadequate cleaning practices. Additionally, a resident with severe cognitive impairment was provided with inadequately cooled food for dialysis, highlighting further deficiencies in food handling and safety.
An LPN failed to maintain resident dignity during medication administration for two residents with cognitive impairments. The LPN entered rooms without knocking and did not ensure privacy by closing doors or pulling curtains, contrary to facility policy. This occurred during medication and insulin administration, with residents exposed to passersby.
A resident who was cognitively intact had been smoking daily for several months without a completed smoking safety assessment until recently. The facility's policy requires such assessments on admission and quarterly, but this was not followed. Interviews with the resident and staff confirmed the resident's regular smoking, and the LPN acknowledged the oversight in conducting the necessary assessments.
A resident admitted with a Foley catheter did not have timely orders for catheter care, leading to a lack of documented care for several days. The resident, with a history of urinary tract infection and neuromuscular bladder dysfunction, experienced symptoms that were not addressed until orders were finally placed. Staff interviews confirmed the expectation for immediate orders upon admission, which was not met in this case.
A facility failed to timely monitor the nutritional status of a dialysis-dependent resident with severe cognitive impairment. Despite physician orders for fluid restrictions and specific dietary needs, the care plan did not address these restrictions for seven weeks. The facility's new remote dietitian had not completed necessary evaluations, and the Minimum Data Set Coordinator was trying to manage dietary care plans due to staffing changes.
A facility failed to follow physician's orders for tube feeding for a resident with traumatic brain injury and gastroesophageal reflux disease. The resident was supposed to receive Jevity 1.5 at 50 ml/hour for 20 hours, but observations showed discrepancies in the administration, with less formula given than prescribed. Despite this, staff reported the resident tolerated the feeding well. The resident, severely cognitively impaired, relied on tube feeding for 100% of nutritional needs.
A facility failed to provide proper tracheostomy care for a resident, as observed when an LPN did not adhere to sterile procedures or perform necessary assessments during care. The resident's care plan lacked specific interventions for tracheostomy care, and staff interviews revealed inconsistencies in understanding care protocols.
A resident's medication regimen review by a consulting pharmacist identified several irregularities, including the use of digoxin, cholestyramine, tramadol, and vitamin D3, which were not addressed by the attending physician. The resident, who was cognitively intact and had recent falls, was out to the hospital during the review period, and the Director of Nursing acknowledged the oversight.
The facility failed to prepare pureed foods to the required smooth consistency for residents with dysphagia, as observed during lunch meals. The pureed foods were lumpy and contained visible pieces, contrary to the facility's policy. The cooks responsible had not received training on preparing pureed diets, affecting residents with physician-ordered pureed diets due to dysphagia and malnutrition.
The facility failed to follow physician-ordered fluid restrictions for two residents, leading to deficiencies in care. One resident received excess fluids during meals due to nursing staff's lack of awareness, while another had multiple bottles of soda and water exceeding the prescribed amount. Interviews revealed a lack of communication and awareness among staff regarding fluid restrictions, impacting the care provided.
A facility failed to accurately document a resident's code status, resulting in a discrepancy between the physician's orders and the resident's care plan. The resident, with severe cognitive impairment, was documented as 'Full Code' in the orders, while the care plan and social services note indicated a 'Do Not Resuscitate' status, as confirmed by the proxy. The error was discovered by an LPN during a record review, and the Social Service Director acknowledged the mistake occurred upon the resident's readmission.
An LPN in a facility failed to perform hand hygiene as per policy during medication administration and tracheostomy care. The LPN did not wash hands before donning or after doffing gloves while administering medication to two residents, one with diabetes and another with a urinary tract infection. Additionally, during tracheostomy care for a resident with a history of traumatic brain injury, the LPN did not perform hand hygiene before starting the procedure or between glove changes.
Food Safety and Handling Deficiencies in LTC Facility
Penalty
Summary
The facility was found to have multiple deficiencies in food storage, preparation, and service during a series of kitchen observations. The storeroom floor was in disrepair with broken concrete and peeling paint, leading to potential contamination. The walk-in refrigerator had rust and mold, and its door gasket was torn, compromising its functionality. The reach-in refrigerator had similar issues with mold and torn gaskets, and improper storage of eggs over milk cartons posed a contamination risk. Leftover food was not discarded within the required timeframe, and equipment such as cutting boards, pans, and dish racks were in poor condition with mold and carbon build-up. Further observations revealed that cleaning practices were inadequate, with a soiled cleaning rag improperly stored and a lack of sanitizer in the cleaning solution. The can opener and juice dispenser were not cleaned regularly, and the ice machine was leaking water onto the floor. Additionally, flying insects were present in the food preparation area, and food temperatures were not maintained at safe levels, with hot foods below 135 degrees F and cold foods above 41 degrees F. A resident with severe cognitive impairment and multiple health conditions, including end-stage renal failure and diabetes, was observed with inadequate food provisions for dialysis. The resident was given ham and cheese sandwiches without proper cooling measures, such as ice packs or an insulated bag, for their dialysis session. This oversight in food safety and handling further highlights the facility's failure to adhere to professional standards for food service safety.
Failure to Maintain Resident Dignity During Medication Administration
Penalty
Summary
The facility failed to ensure residents were treated in a dignified manner during medication administration for two residents. For Resident #38, who has severe cognitive impairment, the LPN entered the room without knocking and did not close the door or pull the privacy curtain while administering medications. This action was contrary to the facility's policy on promoting and maintaining resident dignity, which requires staff to knock or announce their presence and provide privacy during care. Similarly, for Resident #165, who has moderate cognitive impairment and requires insulin administration, the LPN entered the room without knocking and administered insulin with the door open and no privacy curtain pulled. This occurred while the resident was sitting in a wheelchair facing the door, with people passing by in the hallway. The LPN acknowledged during an interview that she should have provided privacy by closing the door or pulling the curtain, indicating a lapse in following the facility's policy on maintaining resident dignity and privacy during medication administration.
Failure to Conduct Smoking Safety Assessment
Penalty
Summary
The facility failed to assess the safety of smoking for a resident who was reviewed for smoking. The facility's policy requires a Resident Smoking Safety Screen to determine if supervision is needed for residents who smoke. However, the resident, who is cognitively intact with a BIMS score of 15, had been smoking daily for several months without a completed smoking safety assessment until 06/24/24. The resident's care plan, initiated on 03/12/24, indicated that smoking assessments should be conducted on admission, quarterly, and as needed, but this was not adhered to. Interviews with the resident and staff confirmed that the resident had been smoking regularly in the facility. The LPN stated that smoking assessments are supposed to be completed on admission and quarterly, but acknowledged that no such assessment had been done for the resident prior to 06/24/24. The admission/readmission nursing evaluation from 04/25/22 indicated that the resident was not smoking at that time, but subsequent evaluations failed to capture the change in the resident's smoking status, leading to a lack of appropriate safety measures.
Failure to Obtain Timely Catheter Care Orders
Penalty
Summary
The facility failed to obtain orders for catheter care for a resident who was admitted with an indwelling Foley catheter. The resident, who had a history of urinary tract infection and neuromuscular dysfunction of the bladder, was readmitted to the facility without any documented orders for Foley catheter care from the time of readmission until several days later. During this period, there was no documentation of catheter care being performed, as evidenced by the Medication Administration Record and Certified Nursing Task records. Interviews with staff revealed that there was an expectation for orders to be placed immediately upon a resident's admission or readmission with a Foley catheter. However, in this case, the orders were not written until several days after the resident's readmission. The resident reported experiencing significant symptoms, including blood in the urine and large white particles in the catheter tubing, which were not addressed until after the orders were finally placed. This oversight in obtaining timely orders for catheter care contributed to the deficiency identified by the surveyors.
Failure to Monitor Nutritional Status for Dialysis Resident
Penalty
Summary
The facility failed to monitor the nutritional status of a resident undergoing dialysis in a timely manner. The resident, who was severely cognitively impaired, was readmitted with diagnoses of End-Stage Renal Failure and Type 2 Diabetes, and was dependent on dialysis. Physician orders included fluid restrictions and specific dietary requirements, but the facility did not address the fluid restrictions in the care plan until seven weeks after the order was given. The care plan was revised to include nutritional interventions, but it did not initially address the fluid restrictions as ordered. The facility's newly hired dietitian, who started working remotely about 1.5 weeks before the interview, had not completed any quarterly nutritional risk evaluations for high-risk residents, including the resident in question. The facility's electronic system did not show a completed quarterly nutritional risk evaluation for the resident. The Minimum Data Set Coordinator was attempting to catch up on dietary care plans due to the facility being between dietitians. The Dietary Manager stated that the Director of Nursing was responsible for contacting the dietitian for high nutritional-risk residents, but there was a delay in addressing the resident's fluid restrictions.
Failure to Follow Tube Feeding Orders
Penalty
Summary
The facility failed to adhere to the physician's orders for tube feeding for a resident with a traumatic brain injury and gastroesophageal reflux disease. The physician's orders specified that the resident should receive Jevity 1.5 tube feeding at a rate of 50 ml per hour for 20 hours, starting at 10:00 AM and stopping at 6:00 AM. However, observations revealed discrepancies in the administration of the tube feeding. On multiple occasions, the amount of formula administered did not match the expected volume based on the prescribed rate, indicating that the resident was not receiving the full nutritional support as ordered. Observations over several days showed that the tube feeding was not being administered correctly. For instance, on one day, only 100 ml of formula was given over four hours, and on another day, only 50 ml was administered in about 4.5 hours. Despite these discrepancies, staff reported that the resident was tolerating the tube feeding well. The resident, who was severely cognitively impaired, relied entirely on tube feeding to meet nutritional needs, as noted in the Nutrition Risk Evaluation. The care plan required monitoring and documentation of residuals and adherence to the ordered tube feedings and flushes, which was not followed as per the physician's orders.
Deficiency in Tracheostomy Care Procedures
Penalty
Summary
The facility failed to provide tracheostomy care in accordance with professional standards of practice for a resident requiring respiratory care. The facility's policy mandates that tracheostomy care should be consistent with professional standards, the comprehensive care plan, and resident preferences. However, the care plan for the resident did not include specific interventions for tracheostomy care, which is a critical oversight given the resident's medical history of traumatic brain injury and the need for attention to a tracheostomy. During an observation, a Licensed Practical Nurse (LPN) provided tracheostomy care to the resident without adhering to sterile procedures. The LPN did not use eye protection, failed to maintain a sterile field, and did not perform hand hygiene appropriately. The LPN also did not listen to breath sounds, check oxygen saturation, or provide suctioning before, during, or after the procedure, despite the resident exhibiting signs of respiratory distress, such as gurgling sounds and copious secretions. Interviews with staff revealed inconsistencies in understanding and executing tracheostomy care procedures. One LPN incorrectly stated that replacing the inner cannula is not a sterile procedure, while another confirmed it should be sterile. The Unit Manager acknowledged that the care plan lacked necessary interventions for tracheostomy care. These discrepancies highlight a lack of standardized training and adherence to protocols, contributing to the deficiency in care provided to the resident.
Failure to Address Pharmacist's Recommendations for a Resident
Penalty
Summary
The facility attending physician failed to document on irregularities identified by the consulting pharmacist for a resident regarding unnecessary medications. The facility's policy requires a licensed pharmacist to perform a monthly drug regimen review, including the resident's medical chart, and for facility staff to act upon all recommendations. However, for one resident, the physician did not address the pharmacist's recommendations concerning the use of digoxin, cholestyramine, tramadol, and vitamin D3, despite the resident's recent falls and hospital stay. The resident, who was cognitively intact, had been admitted to the facility with diagnoses including a fracture of the neck of the right femur, major depressive disorder, and generalized anxiety disorder. The pharmacist's recommendations were not addressed, and there was an indication on the review form that the resident was out to the hospital, but no signature or date was provided. The Director of Nursing acknowledged that the resident was out of the facility for a period in March and admitted that the recommendations must have been missed.
Failure to Prepare Pureed Foods to Required Consistency
Penalty
Summary
The facility failed to prepare food in a form designed to meet the individual needs of five residents with physician-ordered pureed diets. During observations of lunch meals on two consecutive days, surveyors noted that pureed foods, including chicken tenders, baked macaroni & cheese, mixed vegetables, kielbasa, and cabbage, were not pureed to a smooth consistency as required. Instead, the foods were lumpy with visible pieces, which was confirmed through taste testing by both the surveyor and the Certified Dietary Manager (CDM). The lunch cooks responsible for preparing these meals, identified as Staff D and Staff E, admitted to not having received training on preparing pureed foods for residents with dysphagia. The residents affected by this deficiency had diagnoses including dysphagia and protein-calorie malnutrition, with physician orders specifying pureed diets. The residents involved were admitted to the facility at various times, with their pureed diet orders being issued between June 2023 and June 2024. The facility's policy for pureed food preparation, implemented in September 2023, mandates that pureed foods should be smooth and homogenous, similar to soft mashed potatoes, and should not contain any lumps or chunks. However, the facility did not adhere to these guidelines, resulting in the deficiency noted by the surveyors.
Failure to Adhere to Physician-Ordered Fluid Restrictions
Penalty
Summary
The facility failed to adhere to physician-ordered fluid restrictions for two residents, leading to deficiencies in care. Resident #214 had a physician's order for a 1500 cc fluid restriction per day, with specific allocations for dietary and nursing departments. However, during observations, it was noted that the resident had access to a 16-ounce Styrofoam container of water at the bedside, which was not accounted for in the fluid restriction. Additionally, during meal service, the resident received more fluids than prescribed due to a lack of awareness among nursing staff about the fluid restriction, resulting in an extra 240 cc of coffee being served. Resident #22, who was severely cognitively impaired and had a fluid restriction order of 960 ml per day, was also found to have excess fluids in their room. Observations revealed multiple 16-ounce bottles of soda and water, far exceeding the prescribed amount. The resident's care plan did not document the fluid restrictions, and there was no evidence of prior education provided to the family regarding these restrictions. The resident expressed a preference for soda, indicating a lack of understanding or adherence to the fluid restriction. Interviews with facility staff, including the Certified Dietary Manager and Director of Nursing, revealed a lack of awareness and communication regarding the specific fluid amounts to be served with meals. The Certified Nursing Assistant mentioned attending staff meetings where fluid restrictions were discussed, but the observations indicated that this information was not effectively communicated or implemented. The deficiencies highlight a failure in the facility's processes to ensure compliance with physician-ordered fluid restrictions, impacting the care provided to the residents.
Failure to Accurately Document Resident's Code Status
Penalty
Summary
The facility failed to accurately document the code status for a resident, leading to a discrepancy between the resident's documented code status and their actual wishes. The resident, who was admitted with severe cognitive impairment and multiple medical conditions, had a documented code status of 'Full Code' in the physician's orders upon readmission. However, the social services progress note and care plan indicated that the resident was a 'Do Not Resuscitate' (DNR) status, as confirmed by the resident's proxy. This inconsistency was discovered during a review of the resident's records. Interviews with facility staff revealed that the Licensed Practical Nurse (LPN) responsible for checking the resident's code status found the electronic medical record (EMR) dashboard blank and subsequently discovered conflicting documentation in the orders and miscellaneous sections. The Social Service Director (SSD) acknowledged that the resident's code status was incorrectly entered as 'Full Code' upon readmission from the hospital, without his knowledge. The SSD stated that he would have confirmed the code status with the family, who were adamant about maintaining the DNR status due to the resident's health issues.
Failure in Hand Hygiene During Medication and Tracheostomy Care
Penalty
Summary
The facility failed to adhere to its hand hygiene policy during medication administration and tracheostomy care, leading to deficiencies in infection prevention and control. Specifically, an LPN did not perform hand hygiene before donning and after doffing gloves while administering medication to two residents. During a medication pass observation, the LPN handled medications without performing hand hygiene before or after glove use. This was observed in the care of a resident with a urinary tract infection and cognitive communication deficit, as well as another resident with muscle wasting, atrophy, and type 2 diabetes mellitus. Additionally, during tracheostomy care for a resident with a history of traumatic brain injury and aphasia, the same LPN failed to perform hand hygiene before starting the procedure and between glove changes. The resident was observed to have copious secretions during the procedure, which required careful handling to prevent infection. The LPN acknowledged the oversight, attributing it to nervousness and forgetting the proper protocol.
Latest citations in Florida
Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
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