Westminster Suncoast
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Petersburg, Florida.
- Location
- 1095 Pinellas Point Dr S, Saint Petersburg, Florida 33705
- CMS Provider Number
- 105926
- Inspections on file
- 18
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Westminster Suncoast during CMS and state inspections, most recent first.
Surveyors found that multiple residents with skin tears and skin integrity risks did not receive wound care and skin assessments as ordered. For one resident, dressing changes to a lower extremity skin tear were signed as completed every other day, but the dressing was later found still dated from an earlier change, and required steri-strip monitoring on the hand was not documented every shift. Another resident with a left wrist skin tear had a daily dressing order with a missed treatment date and continued every-other-day dressings despite weekly skin inspections documenting intact skin and no clear weekly skin evaluation in the care plan. A third resident with a right wrist skin tear had an order for four days of daily dressings that continued beyond four days without an end date, and this resident’s weekly skin check was overdue despite a care plan intervention for weekly skin checks. These findings showed failures to follow physician orders, accurately document treatments on the TAR, and complete timely weekly skin assessments.
A resident with dementia, fall history, and skin integrity risk had a physician order for right lower extremity skin tear care every other day on the night shift. The Treatment Administration Record showed that wound care was documented as completed on multiple scheduled dates, but the DON later found the dressing still dated from an earlier application, confirming that ordered dressing changes had not been performed for eight days. Two nurses had signed for treatments that were not provided, and weekly skin checks noted non-intact, non-new skin areas without describing the wound or dressing. This resulted in missed physician-ordered wound care and falsified documentation, contrary to the facility’s policies on neglect prevention, wound treatment management, and accurate medical record documentation.
Surveyors found that medications were not consistently secured, including an IV antibiotic bag left on top of an unattended med cart and oral medications left at a resident’s bedside for at least 30 minutes before an RN returned to administer them. The resident involved was cognitively intact, had multiple medical conditions including a healing femur fracture, hypertension, anxiety, and depression, and was receiving several medications such as antidepressants, antianxiety agents, anticoagulants, opioids, antiplatelet agents, levothyroxine, lisinopril, and pravastatin. There was no documentation that the resident was assessed or care planned to self-administer or delay medications, and staff interviews, along with facility policies, confirmed that medications should remain under direct observation or locked and never be left unattended with residents or on med carts.
A resident with impaired cognition and multiple care needs had several shifts where bowel and bladder tasks were left undocumented, despite facility policy requiring complete, factual, and timely documentation of all care or absence of bowel/bladder events by the end of each shift. The DON confirmed that no bowel and bladder tasks should be left blank and that staff must record when no movement occurs. This lack of documentation conflicted with the CNA job description and the facility’s medical record policy, which mandate accurate, complete records reflecting all assessments, observations, and services provided.
Surveyors found that staff failed to follow contact precautions and PPE requirements for two residents on physician-ordered contact isolation. In one case, a CNA entered and interacted with a resident with loose stools and an active order for contact isolation for possible C. diff without wearing gown or gloves, despite a CDC-based Contact Precautions sign on the door and no PPE available at the doorway. In another case, an Activity Assistant entered the room of a resident with an active order for contact isolation for MSSA wound infection without PPE, even though a Contact Precautions sign was posted and the staff member reported prior education on transmission-based precautions. Facility policies required staff to follow CDC-based transmission-based precautions, including donning gown and gloves upon room entry and discarding them before exit, but these practices were not implemented during the observed interactions.
A resident with multiple diagnoses, including dementia and blindness, was subjected to physical abuse by a staff member in an LTC facility. The resident spat at a registered nurse, who retaliated by spitting back multiple times, witnessed by a CNA. The incident was not reported immediately, and the facility failed to protect the resident from further harm, violating its abuse prevention policies.
A resident with a history of mental health issues was involved in an altercation with an RN, who spat back at the resident and held their hands down. The incident, witnessed by a CNA, was not reported until 39 hours later due to fear of retaliation and lack of immediate action by the nursing supervisor. The facility failed to adhere to the required two-hour reporting timeframe for abuse incidents.
The facility failed to ensure an accurate care plan for a resident with multiple diagnoses, including dysphagia and repeated falls. Despite having a DNR order, the care plan incorrectly listed the resident as Full Code. Staff interviews confirmed that care plans should reflect physician orders, which was not done in this case.
The facility failed to ensure that pressure-relieving boots were applied to prevent the worsening of a pressure wound for a resident. Observations revealed the boots were not in use despite physician orders, and documentation contradicted the actual care provided. Interviews indicated that the responsibility for applying the boots lay with the nursing staff, but this was not consistently done.
The facility failed to properly identify and monitor a BIPAP machine for a resident with multiple medical conditions. The resident used a personal BIPAP machine without any orders or documented settings, and the facility did not follow its policy requiring verification and documentation of the machine's use.
The facility failed to ensure ongoing assessment and monitoring of a resident's dialysis fistula, leading to complications such as bleeding and clotting. Despite physician orders and care plan interventions, staff repeatedly did not complete necessary assessments and documentation before and after dialysis treatments. Interviews revealed that the facility's expectations for monitoring and documenting the dialysis fistula were not consistently met, and staff received limited training on dialysis care.
The facility failed to assess and identify triggers for a resident with PTSD, leading to a lack of specific interventions in the care plan. The Social Services Director admitted the oversight, and the Director of Nursing was not knowledgeable about Trauma Informed Care. The facility's policy requires identifying triggers to minimize re-traumatization, which was not followed.
The facility failed to ensure that a private caregiver for a resident with hemiplegia and hemiparesis had the necessary competencies and skills to provide appropriate care. The caregiver, who was not formally trained as a CNA or nurse, was performing ADL care without oversight from facility staff. Interviews revealed that facility staff were either unaware of the caregiver's involvement or assumed her competence without verification.
Failure to Follow Wound Care Orders and Complete Weekly Skin Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care and skin assessments as ordered and care planned for multiple residents with non-pressure wounds and skin integrity risks. For one resident with metabolic encephalopathy, repeated falls, and dementia, a physician’s order directed cleansing of right lower extremity skin tears with normal saline, application of xeroform and ABD pad, and gauze wrap every two days on night shift beginning 6/7/25. Documentation on the Treatment Administration Record (TAR) showed treatments recorded on 6/7, 6/9, 6/11, 6/13, 6/15, and 6/17/25. However, on 6/19/25 the DON documented that the dressing on the right lower extremity was dated 6/11, despite two nurses having signed that dressing changes were completed on 6/13, 6/15, and 6/17, indicating the ordered dressing changes were not actually performed as documented. Weekly skin evaluations for this resident on 6/14/25 indicated the skin was not intact and the areas were not new, but the progress notes for that date did not include information about the skin evaluation or the existing areas. For the same resident, an order on the TAR required monitoring steri-strips on the left hand for signs and symptoms of infection every shift. The TAR showed code “9” (other/see progress notes) on the day shift of 6/11 and the evening shift of 6/15, and a blank entry for the night shift on 6/12, indicating the monitoring was not documented as completed that shift. Progress notes on 6/11 documented wound care provided by the wound care nurse, but notes on 6/11, 6/12, and 6/13 did not explain why the steri-strip monitoring was not completed on the night shift of 6/12. A 6/15 progress note stated staff had not observed the steri-strips to the left hand. The resident’s care plan identified risk for skin breakdown related to assistance needs, nutritional risk, and prior skin tears, and included interventions for monitoring steri-strips for infection every shift, observing skin condition during routine care every shift, providing treatments as ordered, and weekly skin checks. During interview, the DON stated weekly skin checks were done head to toe but staff were focused on identifying new areas and did not pay attention to dressing dates, even though the care plan did not limit checks to new areas only. Another resident with a left wrist skin tear had an order starting 2/13/26 for daily evening-shift treatment with normal saline, xeroform, and dry sterile dressing until resolved. The TAR showed completion from 2/13 through 2/18/26, with the 2/19/26 entry left blank, indicating the treatment was not documented as completed that day. A new order on 2/20/26 for daily day-shift treatment was started and discontinued the same day, while the dressing changes continued every other day thereafter (2/21, 2/23, 2/25/26) despite weekly skin inspections dated 2/14 and 2/21/26 documenting the skin as intact. The care plan for this resident identified potential for skin impairment related to decreased mobility, impaired cognition, incontinence, and a left wrist skin tear, and directed licensed nursing staff to provide treatments as ordered, but did not include weekly skin evaluations. During observation on 2/25/26, the LPN/Unit Manager stated the dressing change was every other day, and the dressing was dated 2/23/26, which did not match the documented daily treatment orders. A third resident with a right wrist dressing reported that the dressing was changed frequently, and the LPN/Unit Manager stated the changes were every other day. However, the provider note documented an order to cleanse with normal saline, pat dry, apply xeroform, and dry dressing for four days, and the TAR showed the treatment order starting 2/19/26 with daily dressing changes documented for six days, without an end date entered as of 2/25/26. The resident’s electronic record showed the weekly skin inspection was two days overdue, with the last completed weekly skin inspection on 2/16/26 despite a care plan intervention for weekly skin checks by licensed nursing staff. The DON acknowledged that the weekly skin check for this resident was overdue. Overall, record reviews, observations, and interviews showed that wound treatments were not consistently provided as ordered, documentation on the TAR was inaccurate or incomplete, and weekly skin assessments were not completed timely or accurately for the sampled residents, contrary to the facility’s Wound Treatment Management policy requiring treatments per physician orders and ongoing assessment and documentation.
Failure to Provide Ordered Wound Care and Falsification of Treatment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide physician-ordered wound care and accurate documentation for a resident with a non-pressure skin tear on the right lower extremity. The resident had diagnoses including metabolic encephalopathy, repeated falls, and unspecified dementia, and was identified as having intermittent confusion, being chairbound, incontinent, and having balance problems. A physician’s order on the Treatment Administration Record (TAR) directed that the right lower extremity skin tears be cleansed with normal saline, patted dry, covered with xeroform and an ABD pad, and wrapped with gauze every two days on the night shift, beginning on 6/7/25. The TAR showed that wound care was documented as completed on 6/7, 6/9, 6/11, 6/13, 6/15, and 6/17/25. However, on 6/19/25, the DON identified that the dressing on the resident’s right lower extremity was still dated 6/11, indicating that the ordered dressing changes had not actually been performed for eight days despite documentation to the contrary. The DON confirmed that two nurses had signed that the dressing changes were completed on 6/13, 6/15, and 6/17, and the surveyor determined that this documentation was false. Weekly skin evaluations documented that the resident’s skin was not intact and that the areas were not new, but there was no further information in the progress notes about the appearance of the wound or the dressing. The resident’s care plan identified risk for skin breakdown related to assistance needs with bed mobility and repositioning, nutritional risk, and prior skin tears, and included interventions such as treatments as ordered, weekly skin checks by licensed staff, and observation of skin condition during routine care. The care plan did not instruct staff to limit skin checks to only new areas, yet the DON stated that staff performing weekly skin checks were focused on identifying new issues and did not pay attention to the date on the existing dressing. Facility policies on abuse, neglect, wound treatment management, and documentation required that ordered treatments be provided as prescribed, that neglect be prevented, and that documentation be factual, accurate, and not false. Despite these policies, the ordered wound treatments were not provided for eight days, and the medical record contained false entries indicating that wound care had been completed as ordered.
Unsecured Medications Left Unattended on Med Cart and at Bedside
Penalty
Summary
The deficiency involves failure to ensure medications were stored securely and not left unattended on medication carts or at residents' bedsides. Surveyors observed a bag of Vancomycin 1 g/200 mL left on top of an unattended medication cart on the 400 hall while the assigned RN was in a resident room on a different hall. The RN later acknowledged the medication should not have been left on top of the cart. The DON stated that medications should not be left unattended on carts, and facility policy on medication storage requires that during a medication pass, medications must be under direct observation of the person administering them or locked in the medication storage area or cart. The deficiency also includes medications left unattended in a resident’s room. A resident was observed with medication at the bedside, and an RN entered the room and immediately went to the medications to administer the remaining dose. The resident reported the medication had been at the bedside for at least 30 minutes and stated staff always leave medications at the bedside so they can take them later. The RN did not comment and removed the empty medication cup after administration. Record review showed this resident was cognitively intact with a BIMS score of 15 and had diagnoses including a left femur neck fracture with routine healing, left hip pain, hypertensive urgency, anxiety disorder, and recurrent moderate major depressive disorder. The resident was receiving multiple medications including antidepressants, antianxiety agents, anticoagulants, opioids, antiplatelet agents, levothyroxine, lisinopril, and pravastatin. There was no documentation in progress notes or the care plan indicating the resident requested to take medications later, no physician or family advisement, and no care plan addressing a tendency to delay or hold medications, despite staff interviews and facility policy stating that medications should not be left unattended with residents.
Failure to Accurately Document Incontinence Care in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records for a resident receiving incontinence care. The resident was admitted with diagnoses including need for assistance with personal care, difficulty in walking, speech and language deficits following cerebrovascular disease, and recurrent moderate major depressive disorder. A Quarterly MDS assessment documented a BIMS score of 9, indicating moderately impaired cognition. Review of the resident’s bowel and bladder task documentation showed multiple shifts on which incontinence care entries were left blank, specifically on 8/28/25 (3–11 shift), 9/8/25 (7–3 shift), 9/11/25 (11–7 shift), 9/12/25 (3–11 shift), 9/30/25 (11–7 shift), and 10/5/25 (3–11 shift). These blanks indicated that care or the absence of bowel/bladder events was not documented as required. During an interview, the DON stated that none of the resident’s bowel and bladder tasks should be blank and that staff are expected to document “no bowel or bladder movement” if no care is needed, with all tasks completed by the end of each shift. The facility’s CNA job description requires CNAs to comply with federal and state regulations, make routine and frequent rounds, and avoid skin problems by providing timely incontinence care and repositioning. The facility’s “Documentation in Medical Record” policy, revised 6/2025, requires that each resident’s record accurately represent the resident’s experiences, with complete, accurate, factual, and timely documentation of all assessments, observations, and services, to be completed no later than the shift in which care occurred. The blank bowel and bladder task entries for this resident demonstrate noncompliance with these documentation standards.
Failure to Ensure Staff Use PPE for Residents on Contact Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective infection prevention and control program by not ensuring staff consistently donned appropriate PPE when caring for residents on contact precautions. For one resident with loose stools and a physician order for contact isolation due to possible Clostridioides difficile (C. diff), a CNA was observed standing in front of the resident, speaking with them, and then leaving the room without wearing any PPE. A Contact Precautions sign from the CDC was posted on the resident’s door, instructing all providers and staff to clean their hands, don gloves and a gown before room entry, and discard them before room exit, and to use dedicated or disinfected equipment. There was no PPE available at the doorway at the time of the observation. During an interview shortly after the observation, the CNA stated that the resident did not have any precautions. The LPN confirmed that the facility was attempting to obtain a stool sample for C. diff because the resident had loose stools. Review of the resident’s record showed an active physician order dated two days prior for “Contact Isolation every shift for possible cdiff for 5 days,” and an order to obtain stool for C. diff and ova and parasites for loose stool for three days. The resident’s diagnoses included multiple fractures of ribs on the left side with routine healing, generalized muscle weakness, and unspecified convulsions. Despite the posted CDC-based Contact Precautions sign and the active contact isolation order, the CNA entered and interacted with the resident without required PPE and later acknowledged that PPE was required and confirmed being in the room without it. A second deficiency event involved another resident with an active physician order for contact isolation every shift for methicillin susceptible Staphylococcus aureus (MSSA) to a wound. An Activity Assistant was observed entering this resident’s room and closing the door without donning any PPE, despite a CDC-based Contact Precautions sign posted on the door that instructed staff to clean their hands before entering and when leaving, don gloves and a gown before room entry, discard them before room exit, and use dedicated or disinfected equipment. No PPE was available in the hallway directly outside the room. The Activity Assistant reported having been educated on transmission-based precautions and PPE use, stated that gloves, mask, gown, and face shield should be worn for contact precautions, and indicated that PPE is used when there are signs on the door. After reading the sign, the staff member noted it included instructions for soap and water hand hygiene. Review of the resident’s record confirmed active orders for contact isolation for MSSA wound infection and enhanced barrier precautions related to IV access and a coude Foley catheter. Review of facility policies showed that the Infection Prevention and Control Program policy required all staff to follow policies and procedures related to infection prevention and to use PPE according to established facility policy, and that residents with infections or communicable diseases be placed on transmission-based precautions per current CDC guidelines. The Transmission-Based (Isolation) Precautions policy defined contact precautions as measures to prevent transmission of infectious agents spread by direct or indirect contact, and specified that healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident’s environment, donning PPE upon room entry and discarding it before exiting. The policy also identified contact precautions with soap-and-water hand hygiene for C. difficile for the duration of illness. Despite these written policies and CDC-based signage, staff did not consistently don required PPE when entering the rooms of residents on contact precautions, and PPE was not available at the doorway for the observed residents.
Failure to Protect Resident from Abuse by Staff
Penalty
Summary
The facility failed to protect the rights of a resident from physical abuse by a staff member. The incident involved a resident who was blind and had multiple diagnoses, including unspecified cerebral infarction, dementia, major depressive disorder, and adjustment disorder. On the evening of the incident, the resident was reportedly combative and refused care, leading to an altercation with a staff member. During the care process, the resident spat at a registered nurse, who then spat back at the resident multiple times. This exchange was witnessed by a certified nursing assistant who reported the incident to a nursing supervisor. The nursing supervisor, however, did not take immediate action to report the incident further, as she was not the supervisor on duty at the time. The registered nurse involved in the incident admitted to spitting back at the resident and holding the resident's hands down during care. The facility's policy on abuse, neglect, and exploitation clearly prohibits such actions, defining abuse as the willful infliction of injury or punishment resulting in physical harm or mental anguish. Despite this, the incident was not reported immediately, and the staff member involved was only suspended after the investigation began. The facility's failure to protect the resident from abuse was compounded by the delay in reporting the incident and the lack of immediate protective measures for the resident. The facility's policy requires immediate response to protect residents from harm and to ensure the integrity of investigations. However, in this case, the resident was left vulnerable to further abuse, and the staff member's actions were not addressed promptly, highlighting a significant deficiency in the facility's adherence to its own policies and procedures.
Delayed Reporting of Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident in a timely manner, as required by regulations. The incident occurred when a resident, who had a history of cerebral infarction, dementia, and other mental health issues, was involved in an altercation with a staff member. The resident, who is blind, was reportedly combative and spat at a registered nurse (RN) during care. In response, the RN spat back at the resident and held the resident's hands down. This incident was witnessed by a certified nursing assistant (CNA), who did not report it immediately. The CNA, identified as Staff A, witnessed the incident on a Saturday night but did not report it until the following Monday afternoon, approximately 39 hours later. The delay in reporting was due to fear of retaliation from the RN involved, as well as a lack of immediate action by the nursing supervisor on duty, who advised the CNA to write a statement but did not escalate the report. The facility's policy requires that such incidents be reported within two hours if they involve abuse, which was not adhered to in this case. The facility's management, including the Nursing Home Administrator (NHA), Director of Nursing (DON), and Regional Health Care Director (RHCD), were informed of the incident only after the delay. They acknowledged the failure to report the incident promptly and noted that the staff involved did not follow the established procedures for reporting abuse. The incident was eventually reported to the state agency and law enforcement, but not within the required timeframe, highlighting a significant deficiency in the facility's handling of abuse allegations.
Failure to Ensure Accurate Advanced Directives in Care Plan
Penalty
Summary
The facility failed to ensure an accurate care plan was in place related to Advanced Directives for one resident. The resident was admitted with multiple diagnoses, including dysphagia, muscle weakness, and repeated falls. Despite having a physician order for Do Not Resuscitate (DNR) dated 4/21/24 and a State of Florida's DNR Order completed by the resident's Durable Power of Attorney and signed by the physician on 3/30/24, the resident's care plan dated 4/5/24 incorrectly listed the resident as Full Code. This discrepancy indicates that the care plan did not reflect the resident's actual advanced directives as documented in the physician orders and state DNR order. Interviews with staff, including the Assistant Social Worker, Director of Nursing (DON), and Nursing Home Administrator (NHA), confirmed that the care plans should accurately reflect the physician orders. The Assistant Social Worker explained that Advanced Directives are obtained by the social services department upon admission and followed up by the nurses after hours. The DON and NHA confirmed that staff should refer to the physician order in the electronic medical record and the hard chart to determine the code status, not the care plan. The facility's policy on Comprehensive Care Plans emphasizes the need for accurate and person-centered care plans, which was not adhered to in this case.
Failure to Apply Pressure-Relieving Boots
Penalty
Summary
The facility failed to ensure that pressure-relieving boots were applied to prevent the worsening of a pressure wound for a resident. Observations on two consecutive days revealed that the resident was in bed with the air boots placed on a chair next to the bed, not in use, despite physician orders for the boots to be applied while in bed every shift. The Treatment Administration Record (TAR) indicated that the boots were documented as administered, although observations contradicted this documentation. Additionally, there was no documentation related to floating heels while in bed every shift as per another physician's order. The resident's medical history included dysphagia, muscle weakness, and repeated falls, among other conditions. The resident had a pressure wound on the left lateral heel, which was documented as stable but required specific treatments, including the use of air boots and floating heels. Interviews with the Director of Nursing (DON) and a Certified Nursing Assistant (CNA) revealed that the responsibility for applying the boots lay with the nursing staff, but the boots were not consistently applied as required. The facility's policy on assistive devices emphasized the need for proper and consistent use based on the resident's care plan, but this was not adhered to in this case.
Failure to Monitor and Document BIPAP Machine Use
Penalty
Summary
The facility failed to ensure proper identification and monitoring of a BIPAP machine for a resident. Resident #6, who had medical diagnoses including heart failure and Type 2 Diabetes Mellitus, was observed using a BIPAP machine that he brought from home. The resident was able to put on and remove the BIPAP mask himself. However, a review of his medical record did not reveal any orders related to the BIPAP machine, and his care plan only mentioned CPAP/BIPAP therapy without specific details or settings for the BIPAP machine. An interview with the Director of Nursing confirmed that there should have been an order for the BIPAP settings and that a respiratory therapist should have been involved in confirming the settings. The facility's policy on noninvasive ventilation required obtaining an order for the use of CPAP/BIPAP devices and verifying the settings on any personal devices brought into the facility. The policy also mandated documentation of the machine's use, the resident's tolerance, and any changes in the resident's condition, which was not done in this case.
Failure to Monitor Dialysis Fistula
Penalty
Summary
The facility failed to ensure ongoing assessment and monitoring of the dialysis fistula for a resident requiring dialysis services. The resident, who had a history of End Stage Renal Disease and dependence on renal dialysis, experienced complications with her dialysis access port, including bleeding and clotting. Despite physician orders and care plan interventions requiring thorough monitoring and documentation of the dialysis fistula, the facility staff repeatedly failed to complete the necessary assessments and documentation before and after dialysis treatments. This included not recording vital signs, thrill and bruit assessments, and signs of bleeding or infection on multiple occasions, as evidenced by the incomplete Dialysis Communication Inter-Change forms and progress notes reviewed by surveyors. On several dates, including 4/3/24, 4/5/24, 4/8/24, 4/10/24, 4/22/24, and 4/24/24, the required assessments and documentation were not completed. The resident was admitted to the hospital on 4/8/24 due to a clot in the dialysis fistula, and upon returning to the facility on 4/10/24, no assessment of the fistula was recorded. The resident experienced significant bleeding from the fistula on 4/11/24, which was not promptly addressed due to the lack of ongoing monitoring and documentation by the facility staff. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and other staff members revealed that the facility's expectations for monitoring and documenting the dialysis fistula were not consistently met. Staff members acknowledged the importance of completing the dialysis communication forms and conducting thorough assessments but admitted that these tasks were not always performed. The facility's education on dialysis care was described as primarily web-based, with some staff indicating that they had received limited training on the specific requirements for monitoring dialysis fistulas.
Failure to Identify PTSD Triggers for Resident
Penalty
Summary
The facility failed to ensure that a resident with Post Traumatic Stress Disorder (PTSD) was assessed to identify triggers that could potentially re-traumatize the resident. Resident #72, who has a history of trauma related to verbal and physical abuse, was admitted with diagnoses including unspecified dementia, anxiety, and PTSD. The resident's care plan included general interventions for trauma but did not specify any triggers that could re-traumatize the resident. The Social Services Director admitted that they did not ask the resident or her daughter about specific triggers during the initial assessment. During interviews, the Social Services Director acknowledged the oversight and stated that triggers should have been identified and documented. The Director of Nursing was not well-versed in Trauma Informed Care and relied on the Social Services Director for information. The Nursing Home Administrator stated that the Social Services Director would reassess all residents with PTSD to update their care plans and provide staff education on trauma-informed care. The facility's policy on Trauma Informed Care mandates the identification of triggers to minimize re-traumatization, which was not followed in this case.
Failure to Ensure Competency of Private Caregiver
Penalty
Summary
The facility failed to ensure that a private caregiver for a resident had the necessary competencies and skills to provide appropriate care. The resident, who had been admitted with diagnoses including hemiplegia and hemiparesis following a stroke, was being cared for by a private caregiver who was not formally trained as a Certified Nursing Assistant (CNA) or nurse. The private caregiver was performing activities of daily living (ADL) care such as transferring the resident to the bathroom, giving showers, and dressing the resident, without any formal training or oversight from the facility staff. The caregiver reported that she had to perform these tasks because the facility staff were slow to respond to call lights and had indicated that other private caregivers were providing care, so she could too. Facility staff, including CNAs and the Director of Nursing (DON), were either unaware of the private caregiver's involvement or assumed that the caregiver was competent without verifying her qualifications or providing necessary training. Interviews with the Nursing Home Administrator (NHA) and the DON revealed that they were not fully aware of the extent of the private caregiver's involvement in providing ADL care. The NHA acknowledged that the private caregiver was working outside her scope and that the facility staff should be providing the care. The private caregiver was subsequently educated that her role was limited to companionship and light domestic services, and that the facility staff were responsible for all ADL care. The resident's family member also expressed concerns that the private caregivers were providing hygiene care because the facility staff were not fulfilling their responsibilities. This situation highlighted a significant lapse in ensuring that caregivers had the appropriate competencies and skill sets to meet the resident's care needs.
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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