Willowbrooke Court At St Andrews Estates
Inspection history, citations, penalties and survey trends for this long-term care facility in Boca Raton, Florida.
- Location
- 6152 N Verde Trail, Boca Raton, Florida 33433
- CMS Provider Number
- 105355
- Inspections on file
- 17
- Latest survey
- May 1, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Willowbrooke Court At St Andrews Estates during CMS and state inspections, most recent first.
The facility failed to follow food safety standards by storing raw chicken and Mighty Shakes in the refrigerator beyond recommended time frames. The DCS incorrectly believed the chicken was safe for a week and that it was Cryovac packaged, which was not true. Additionally, Mighty Shakes were stored for a month, exceeding the 14-day limit after removal from the freezer. This affected 42 of 44 residents on oral diets.
The facility failed to maintain accurate records for controlled drugs for a resident, with discrepancies found in the documentation of medication administration. Despite staff describing the correct procedure, the records did not reflect the administration of the medication as required by the facility's policy.
The facility failed to secure medication and treatment carts and improperly disposed of medications. An LPN left a treatment cart unlocked and unattended, and a medication cart was found unsecured on a hallway. An RN left medications unattended during administration and improperly discarded crushed medications in the garbage instead of using the Drug Disposal bottle.
A facility failed to ensure proper feeding tube management for a resident with severe mental status, as an LPN did not verify tube placement before feeding. Additionally, an RN did not adhere to medication administration standards, relying on memory instead of verifying the MAR. The DON and Administrator acknowledged these deficiencies, noting issues with staff orientation.
A resident with severe cognitive impairment and requiring tube feeding was not provided appropriate care to prevent feeding complications. An LPN connected the feeding tube without verifying its placement or patency, contrary to facility policy. The resident's care plan emphasized the importance of these checks to prevent complications, but they were not performed as required.
A registered nurse (RN) at a facility failed to follow proper medication administration procedures, as observed during a survey. The RN, who had recently transitioned from an LPN, crushed medications and left them unattended in a cart drawer while retrieving necessary items and resolving computer access issues. The RN admitted to not having the MAR on hand and relied on memory and prior access from another computer. The facility's DON and Administrator acknowledged the RN's incomplete orientation and the need for further training.
A facility failed to maintain accurate records for controlled drugs, as evidenced by discrepancies in the documentation for a resident's medication. The facility's policy requires that each dose be documented on both the control sheet and eMAR, but records showed missing entries for administered doses. Interviews with staff confirmed the process, yet the records were incomplete, indicating a failure to follow protocol.
The facility failed to monitor and document the behaviors of two residents as per physician's orders, leading to a deficiency in ensuring drug regimens are free from unnecessary drugs. Despite having orders to monitor specific behaviors and document interventions, the facility's records lacked the necessary documentation, which was confirmed by the DON during a review.
The facility failed to secure medication and treatment carts and improperly disposed of medications. An LPN left a treatment cart unlocked and unattended, and a med cart was found unsecured on a hallway. An RN left dispensed medications unattended and disposed of crushed medications improperly, contrary to facility policy.
The facility failed to follow proper infection control and hygiene practices during medication administration and resident care. An LPN did not wear a gown while connecting a feeding tube for a resident on Enhanced Barrier Precautions, and an RN did not perform hand hygiene during medication administration. These actions were contrary to the facility's policies, leading to deficiencies in infection prevention and control.
The facility was found deficient in ensuring that bathrooms were equipped with a functioning resident call system. Observations showed that emergency pull cords in four bathrooms were wrapped around grab bars, making them inoperable. The Maintenance Technician acknowledged the issue and stated that regular checks would be conducted to prevent this problem.
The facility failed to maintain egress doors with delayed egress locking arrangements as per NFPA 101 standards. During a tour, it was observed that the delayed egress doors in the Coconut Grove hallway did not open when tested. The Director of Property Management and the Administrator acknowledged the findings during an interview.
The facility failed to maintain its HVAC system as per NFPA 101 standards, with non-operational exhaust fans in soiled utility rooms in both the east wing of Pineapple Trail and the west wing of Lakeshore. The deficiency was observed during a facility tour with the Director of Property Management, and acknowledged by the Administrator.
The facility failed to maintain documentation for two generator monthly conductance tests, as required by NFPA 99 standards. This deficiency was identified during a record review with the Director of Property Management, and acknowledged by the Administrator and Director of Property Management.
Improper Food Storage Practices
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by improper storage of raw chicken and Mighty Shakes in the refrigerator beyond recommended time frames. During an inspection, it was observed that a box of boneless, skinless chicken was stored in the refrigerator for six days, exceeding the USFDA's recommended storage time for raw chicken. The Director of Culinary Services (DCS) incorrectly believed that the chicken was safe for use for about one week and that it was packaged with Cryovac, which was not the case. Additionally, a box of Mighty Shakes was found in the refrigerator with a date indicating it had been received from the vendor about a month prior. The DCS and Staff B were unaware that the Mighty Shakes should be used within 14 days after being removed from the freezer. The surveyor informed them of the correct storage guidelines, which were confirmed by the facility's sales representative. The DCS relied on information from the distributor, which stated that the chicken had a shelf life of 16 days, but this did not specify refrigeration or freezing conditions. The surveyor clarified that the chicken was not packaged with a low-oxygen method, as initially claimed by the DCS. The facility's failure to follow proper food safety standards had the potential to affect 42 of 44 residents on oral diets.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: The box of chicken and mighty shake was discarded. Identification of other residents potentially affected: Current residents have the potential to be affected; however, based on inspection and not using the chicken or mighty shake no residents were affected. Measures: On re-education provided by the Director of Culinary Services to the culinary team members on following the standards of professional practice for food safety. Following the culinary services policy and procedures food storage chart for dry food and refrigerated storage. New team members will be educated to follow the standards of professional practice for food safety upon hire. Monitoring: The Director of Culinary Services/Executive Chef will complete daily audits for 4 weeks and then weekly for 2 months to ensure all items are following the professional practice for food safety. The Director of Culinary Services will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 3 months or until the committee determines substantial compliance.
Failure in Controlled Drug Record-Keeping
Penalty
Summary
The facility failed to maintain an accurate system of records for the receipt and disposition of controlled drugs, specifically for one resident. The facility's policy on controlled substances management requires strict handling, storage, disposal, and record-keeping, including signing off each dose on the control sheet and electronic medication administration record (eMAR). However, a review of the records for a resident revealed discrepancies in the documentation of controlled medication administration. Specifically, there was no documentation on the eMAR for doses of a controlled medication that were removed from the supply at 1:30 AM and 7:00 AM on a particular day. Interviews with nursing staff revealed inconsistencies in the process of documenting the administration of controlled medications. A registered nurse and a licensed practical nurse both described the procedure of removing medication, marking it on the control sheet, and signing it off on the MAR once administered. Despite this, the records for the resident in question did not reflect the administration of the medication as per the facility's policy, indicating a failure in the system of record-keeping for controlled substances.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation, the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: On resident #4, screening completed, resident's level was noted to be at zero. On licensed nurses were re-educated by the Director of Nursing on the importance of ensuring all medication administrations are signed off in pharmacy log and on Medication Administration Record (MAR) in Point Click Care for accurate account of controlled medications. Identification of other residents potentially affected: Quality review audit of completed. Current residents have the potential to be affected; resident #4 was not affected. Measures: On licensed nurses were re-educated by the Director of Nursing on the importance of ensuring all medications administration are signed off in pharmacy log and on Medication Administration Record (MAR) in Point Click Care for accurate account of controlled medications. In-services/training will be completed for newly hired licensed nurses. Monitoring: The Director of Nursing/nursing team will complete daily audits during clinical meeting for 4 weeks and then weekly x 3 months to ensure records are in order and that an account of all controlled drugs is maintained and reconciled. Director of Nursing will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 4 months or until the committee determines substantial compliance.
Medication and Treatment Cart Security and Disposal Deficiencies
Penalty
Summary
The facility failed to secure medication and treatment carts, as well as properly dispose of medications, during observations conducted by surveyors. An unlocked and unattended treatment cart, identified as the Pineapple treatment cart, was observed next to the East Reception Desk containing several prescription medications. A Licensed Practical Nurse (LPN) acknowledged the cart was left unlocked and unattended, contrary to the facility's policy that requires all medications and biologicals to be securely stored in locked cabinets or carts. Additionally, an unsecured and unattended medication cart was found on the Oasis hallway during an environmental tour with the Administrator and Maintenance Tech, who immediately called for the nurse responsible. During a medication administration observation, a Registered Nurse (RN) left dispensed medications unattended on top of a medication cart while she walked across the hallway to use a wall sanitizer dispenser. The RN also improperly disposed of crushed medications by discarding them in the garbage container attached to the medication cart, instead of using the designated Drug Disposal bottle. These actions were not in compliance with the facility's policy for medication storage and disposal, which requires medications to be disposed of in a manner that ensures accurate reconciliation and security.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: Carts were locked immediately. Re-education was provided to the licensed nurse assigned to east wing to ensure treatment and medication carts are kept locked and secure. Identification of other residents potentially affected: Current residents have the potential to be affected; no other resident was affected. Measures: On re-education initiated to licensed nurses by the Director of Nursing on proper storage of drugs and biologicals. Keeping treatment and medication carts locked and secured. In-service/training will be completed for newly hired licensed nurses. Monitoring: The Director of Nursing/nursing team will complete daily audits for 4 weeks and then weekly x two months to ensure proper storage of drugs and biologicals and keeping treatment and medication carts locked and secured. The Director of Nursing will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 3 months or until the committee determines substantial compliance.
Deficiencies in Feeding Tube Management and Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of feeding for a resident who was admitted with several medical conditions, including a severe mental status. The resident had specific physician orders for feeding tube management, which included checking tube placement before feeding or medication administration, and ensuring the tube's patency. However, during an observation, a Licensed Practical Nurse (LPN) connected the feeding tube without verifying its placement or patency, contrary to the facility's policy and the resident's care plan. Additionally, the facility did not ensure that all nursing staff met professional standards of quality and competency. During a medication administration observation, a Registered Nurse (RN) was found to have crushed medications and stored them in a medication cart drawer without having the necessary equipment, such as a laptop, to verify the medication administration record (MAR) at the time. The RN admitted to relying on her memory and previous access to the MAR on another computer, which was not in line with the facility's standards for medication administration. The Director of Nursing (DON) and the Administrator acknowledged the deficiencies, noting that the RN was new to the facility and had not completed the required orientation checklist for professional staff. The Administrator expressed concern over the RN's preparedness and the inconsistency in the orientation process, which was previously managed by an Assistant Director of Nursing who had been terminated for inconsistent work performance.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation, the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: Resident #43 was assessed by the Director of Nursing for signs of feeding intolerance, placement, and residual. Resident #43 was tolerating feeding okay, placement was confirmed with no residual. On re-education on feeding administration was immediately provided to staff A, the licensed Practical Nurse. Identification of other residents potentially affected: Current residents have the potential to be affected; however, based on the residents' assessment and observation completed, no resident was affected. Measures: Staff A was provided with competency skills training on Feeding Administration by the Director of Nursing. a. Verifying the five rights of administration b. Safety & Proper Positioning c. Tube Placement d. Residual e. Flush f. Control On Relias training was completed by staff A on feeding. Inservice/training will be completed for newly hired licensed nurses. Monitoring: The Director of Nursing/nursing team will complete daily audits for 4 weeks and then weekly for 2 months to ensure licensed nurses follow the policy and procedure and provide appropriate treatment and services to prevent complications of feeding. The Director of Nursing will report the findings to the Quality Assurance Performance Improvement Committee Monthly for 3 months or until the committee determines substantial compliance.
Failure to Verify Feeding Tube Placement
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of feeding for a resident who was reviewed for feeding management. The resident, identified as Resident #43, was admitted with several diagnoses, including severe cognitive impairment, and required tube feeding for nutrition and hydration. The facility's policy required checking the placement and patency of the feeding tube before each feeding or medication administration. However, during an observation, a Licensed Practical Nurse (LPN) connected the feeding tube to the resident without verifying the tube's placement or patency, contrary to the facility's policy. The resident's care plan highlighted the risk of complications due to the tube feeding status and included specific interventions to mitigate these risks, such as checking tube placement and providing flushes as ordered by the medical doctor. Despite these directives, the LPN did not perform the necessary checks before initiating the feeding, which could potentially lead to complications. The LPN later stated that she had checked the tube between 12:00 PM and 1:00 PM during medication administration, but this did not align with the requirement to check before each feeding connection.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: On resident #43 was assessed by the Director of Nursing, for signs of feeding intolerance, placement and residual. Resident #43 was tolerating feeding ok, placement was confirmed with no residual. On , Re-education on feeding administration was immediately provided to staff A, the licensed Practical Nurse. Identification of other residents potentially affected: Current residents have the potential to be affected; however, based on the residents assessment and observation completed, no resident was affected. Measures: On staff A was provided with competency skills training on Feeding Administration by the Director of Nursing. a. Verifying the five rights of administration b. Safety & Proper Positioning c. Tube Placement d. Residual e. Flush f. Control On , Relias training was completed by staff A, on feeding. Inservice/training will be completed for newly hired licensed nurses. Monitoring: The Director of Nursing/nursing team will complete daily audits for 4 weeks and then weekly x 2 months to ensure licensed nurses follow the policy and procedure for and provide appropriate treatment and services to prevent complications of feeding. The Director of Nursing will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 3 months or until the committee determines substantial compliance.
Deficiency in Medication Administration Process
Penalty
Summary
The facility failed to ensure that all nursing staff adhered to professional standards of quality during medication administration, as evidenced by the actions of one registered nurse (RN), Staff D. During a medication administration observation, Staff D was seen crushing medications and storing them in the top drawer of a medication cart without having the necessary apple sauce to administer them. She left the cart to retrieve the apple sauce and a laptop computer, which she needed to access the Medication Administration Record (MAR). Upon returning, she was unable to log into the laptop and left again to resolve the issue, leaving the medications unattended for several minutes. Staff D, who had been working at the facility for a month and had recently transitioned from a Licensed Practical Nurse (LPN) to an RN, admitted to the surveyor that she would discard the crushed medications because the resident was not in their room. She also revealed that she had accessed the MAR on another computer located at the nurses' station, rather than having it available on the medication cart as per facility standards. Staff D mentioned that the laptop she was using often gave her problems, and although management was aware, the issue persisted. The Director of Nursing (DON) expressed concern over the incident, noting that medication administration procedures had been recently reviewed and that Staff D was a new nurse. The facility's Administrator confirmed that Staff D had not completed the Orientation Checklist for Professional Staff, which was the responsibility of the Assistant Director of Nursing (ADON), who had been terminated for inconsistent work. A review of Staff D's orientation checklist indicated that she required further education on preparing and organizing for medication administration.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: Staff D, the Registered Nurse, was immediately pulled from the assignment. On staff D was re-educated by the Director of Nursing on medication administration and management to ensure safe and efficient administration of medications to residents. Dispensing, dose preparation and follow the correct medication administration guidelines. Specific competencies and skill set necessary to provide nursing and related services to meet the residents' needs safely. Identification of other residents potentially affected: Current residents have the potential to be affected; however, based on the resident assessment and observation completed, no resident was affected. Measures: On staff D was provided with competency skills training by the Director of Nursing to ensure staff D possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely. a. Verifying the five rights of administration: right person, medication, route, time, and dose. b. Prepare: Place medication in cup, if medication needs to be or can be crushed. c. Control: Perform hygiene. Use control measures and standard precautions. d. Administration. e. Documentation. On , licensed nurses were re-educated by the Director of Nursing on medication administration and management to ensure safe and efficient administration of medications to residents. Dispensing, dose preparation and follow the correct medication administration guidelines. Specific competencies and skill set necessary to provide nursing and related services to meet the residents' needs safely. Training and orientation competency skills will be completed for newly hired licensed nurses. On , Relias training on medication administration and management was completed by staff D, registered nurse. On , staff D and completed 1:1 training with senior registered nurse to ensure medication administration processes are followed. Monitoring: The Director of Nursing/nursing team will complete daily audits for 4 weeks and then weekly audits x 3 months to ensure licensed nurses are following the medication administration process and possess competency skill sets to provide nursing and related services to meet residents' needs safely. The Director of Nursing will report the findings to the Quality Assurance Performance Improvement Committee Monthly x 4 months or until the committee determines substantial compliance.
Failure to Maintain Accurate Controlled Drug Records
Penalty
Summary
The facility failed to maintain a comprehensive system of records for the receipt and disposition of controlled drugs, which is necessary for accurate reconciliation. This deficiency was identified during a review of records for a resident who was prescribed controlled medications. The facility's policy on controlled substances requires that each dose administered be documented on both the control sheet and the electronic medication administration record (eMAR). However, discrepancies were found in the documentation for a resident who had been prescribed a 50 mg oral tablet to be taken as needed. Specifically, the controlled medication utilization record indicated that tablets were removed at specific times, but there was no corresponding documentation in the medication administration record for those times. Interviews with facility staff, including a registered nurse and a licensed practical nurse, revealed that the process for handling controlled medications involves removing the medication, marking it on the control sheet, and signing it off on the MAR once administered. Despite this procedure, the records for the resident in question were incomplete, indicating a failure to adhere to the established protocol. This lapse in documentation and record-keeping for controlled substances was observed for one of the five sampled residents, highlighting a significant oversight in the facility's pharmacy services.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: On resident #4 screening completed, residents, level was noted to be at zero. On licensed nurses were re-educated by the Director of Nursing on the importance of ensuring medication administrations are signed off in pharmacy log and on Medication Administration Record (MAR) in Point Click Care for accurate account of controlled medications. Identification of other residents potentially affected: Quality review audit of completed. Current residents have the potential to be affected; resident #4 was not affected. Measures: On , licensed nurses were re-educated by the Director of Nursing on the importance of ensuring all medications administration are signed off in pharmacy log and on Medication Administration Record (MAR) in Point Click Care for accurate account of controlled medications. In-services/training will be completed for newly hired licensed nurses. Monitoring: The Director of Nursing/nursing team will complete daily audits during clinical meeting for 4 weeks and then weekly x 3 months to ensure records are in order and that an account of all controlled drugs is maintained and reconciled. Director of Nursing will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 4 months or until the committee determines substantial compliance.
Failure to Monitor and Document Resident Behaviors
Penalty
Summary
The facility failed to adequately monitor and document the behaviors of two residents, leading to a deficiency in compliance with the requirement that each resident's drug regimen must be free from unnecessary drugs. Resident #7, who was admitted with severe cognitive impairment, had a physician's order to monitor specific behaviors and document interventions. However, there were instances where behaviors were observed, but no intervention codes or detailed documentation were recorded in the nursing progress notes or Medication Administration Record (MAR). Similarly, Resident #23, also with severe cognitive impairment, had a physician's order to monitor behaviors and document interventions using specific codes. The MAR showed check marks instead of the required 'Yes' or 'No' to indicate the presence of symptoms, and there was a lack of documentation in the progress notes regarding the resident's behavior and the interventions implemented. This lack of documentation and adherence to physician's orders was acknowledged by the Director of Nursing during a review of the residents' records. Interviews with staff, including a Licensed Practical Nurse and a Registered Nurse, revealed that while there was an understanding of the need to monitor and document behaviors, the actual practice did not align with the facility's policy or the physician's orders. The Director of Nursing confirmed the deficiency in documentation, which contributed to the facility's failure to meet the regulatory requirement of ensuring residents' drug regimens are free from unnecessary drugs.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation, the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: On __, residents #7 and #23 clinical charts were reviewed. Licensed nurses were re-educated on following physicians orders for monitoring of behavior and documentation of intervention codes. Identification of other residents potentially affected: Quality review audit of current residents at risk for behavioral monitoring and interventions was completed. No other residents were affected. Measures: On re-education initiated to licensed nurses by the Director of Nursing on following physician orders for monitoring of behavior and documentation of intervention codes. In-service/training will be completed for newly hired licensed nurses. Monitoring: The Director of Nursing/nursing team will complete daily audits during clinical meeting for 4 weeks and then weekly x 3 months to ensure physicians orders are being followed for behavior monitoring and documentation to ensure the appropriate treatment and or behavioral interventions are being used to meet the needs of the residents. Director of Nursing will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 4 months or until the committee determines substantial compliance.
Medication and Treatment Cart Security Lapses
Penalty
Summary
The facility failed to secure medication and treatment carts, as well as properly dispose of medications, during observations conducted by surveyors. An unlocked and unattended treatment cart, identified as the Pineapple treatment cart, was found next to the East Reception Desk containing several prescription medications. A Licensed Practical Nurse (LPN) acknowledged the cart was left unlocked and unattended, contrary to facility policy which requires all medications and biologicals to be securely stored in locked cabinets or carts. Additionally, during an environmental tour, an unsecured and unattended medication cart was observed on the Oasis hallway. The Administrator had to call for the nurse to address the issue. Furthermore, during a medication administration observation, a Registered Nurse (RN) left dispensed medications unattended on top of a medication cart while she walked across the hallway to use a wall sanitizer dispenser. The RN also improperly disposed of crushed medications in a garbage container attached to the medication cart, instead of using the designated Drug Disposal bottle, as per facility policy.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: Carts were locked immediately. Re-education was provided to the licensed nurse assigned to east wing to ensure treatment and medication carts are kept locked and secure. Identification of other residents potentially affected: Current residents have the potential to be affected; no other resident was affected. Measures: On , re-education initiated to licensed nurses by the Director of Nursing on proper storage of drugs and biologicals. Keeping treatment and medication carts locked and secured. In-service/training will be completed for newly hired licensed nurses. Monitoring: The Director of Nursing/nursing team will complete daily audits for 4 weeks and then weekly x two months to ensure proper storage of drugs and biologicals and keeping treatment and medication carts locked and secured. The Director of Nursing will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 3 months or until the committee determines substantial compliance.
Deficiencies in Infection Control and Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper hygiene and personal protective equipment (PPE) protocols during medication administration and resident care, leading to deficiencies in infection prevention and control. During an observation, a Licensed Practical Nurse (LPN) did not wear a gown while connecting a resident's feeding tube, despite the resident being on Enhanced Barrier Precautions due to a medical condition. The LPN acknowledged the need for gown and gloves but did not comply, citing the task's simplicity as the reason for not wearing a gown. In another instance, a Registered Nurse (RN) failed to perform hand hygiene during a medication administration process. The RN donned clean gloves without washing hands, crushed medications, and handled a medication capsule without performing hand hygiene between glove changes. This oversight was acknowledged by the RN during an interview, indicating a lapse in following the facility's hygiene protocols. The resident involved in the first incident had a history of medical conditions requiring tube feeding and was at risk for nutritional issues. The facility's policies on isolation precautions and hand hygiene were not followed, as evidenced by the staff's actions during the observations. These deficiencies highlight lapses in the facility's infection prevention and control program, as outlined in their policies.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: A. Staff A and staff D were immediately re-educated on Control practices. B. Staff A and staff D were re-educated on performing hygiene during care and medication administration and following guidelines for Enhanced Barrier Precautions (EBP) by wearing appropriate Personal Protective Equipment (PPE) during high-contact resident care activities. Identification of other residents potentially affected: Quality Review audit related to control practices was completed. Any issues identified were addressed at that time. No other resident was affected. Measures: On licensed nurses were re-educated on the 5 moments of Hygiene. a. Before patient contact. b. Before a task. c. After exposure risk. d. After patient contact. e. After contact with patient surroundings. Education on control practices and programs have been provided. Handwashing with return demonstration completed for current team members. Re-educated current team members on performing hygiene during care and medication administration and following guidelines for Enhanced Barrier Precautions (EBP) by wearing appropriate Personal Protective Equipment (PPE) during high-contact resident care activities. Prevention and control training will be completed for newly hired team members. Monitoring: The Director of Nursing/ADON Preventionist will conduct weekly random rounds x twelve weeks to monitor for compliance in control practices including hygiene and wearing appropriate Personal Protective Equipment (PPE) during high-contact resident care. The Director of Nursing will report the findings to the Quality Assurance Performance Improvement Committee monthly x 3 months or until the committee determines substantial compliance.
Deficiency in Resident Call System in Bathrooms
Penalty
Summary
The facility failed to ensure that bathrooms were adequately equipped with a functioning resident call system, as required by §483.90(g). Observations revealed that in four out of seventy-three bathrooms, the emergency pull cords were wrapped around grab bars, rendering them inoperable. This issue was identified in bathrooms located next to the Oasis Kitchen, the Social Worker office, and other unspecified locations within the facility. The inability to activate the emergency pull cords was confirmed through multiple observations conducted at different times. During a tour of the facility, both the Maintenance Technician and the Administrator acknowledged the issue with the emergency pull cords being wrapped around the grab bars. The Maintenance Technician stated that they would ensure regular rounds are conducted to check the emergency pull cords. However, the report does not mention any corrective actions taken at the time of the observations or any immediate plans to rectify the deficiency.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation, the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: Call system were unwrapped from the grab bar in the residents bathroom immediately. Identification of other residents potentially affected: Current residents have the potential to be affected; however, based on inspection, no residents were affected. Call light strings in residents bathroom were inspected throughout the units to ensure compliance with resident call system. No other resident call system was identified out of compliance. Measures: On [date], team members were re-educated on ensuring the call system cord is not wrapped around a grab bar. The call system must be adequately equipped to allow residents to call for staff assistance through a communication system. Inservice will be completed for newly hired team members. Monitoring: The Director of Property Management and Maintenance Assistants will complete daily audits for 4 weeks and then weekly for two months to ensure compliance with resident call system standards. The Director of Property Management will report the findings to the Quality Assurance Performance Improvement Committee Monthly for 3 months or until the committee determines substantial compliance.
Egress Door Compliance Failure
Penalty
Summary
The facility failed to maintain their egress doors equipped with delayed egress locking arrangements in accordance with NFPA 101 standards. During a facility tour conducted on April 29, 2025, between 1:15 PM and 2:45 PM, it was observed that the delayed egress doors located in the Coconut Grove hallway did not open when tested. This issue was identified in the presence of the Director of Property Management, who was accompanying the surveyors during the inspection. An interview with the Administrator and the Director of Property Management was conducted concurrently with the observations, during which they acknowledged the findings. The deficiency was reviewed with both the Administrator and the Director of Property Management at the exit meeting on the same day at 3:00 PM. The failure to maintain the egress doors in compliance with the NFPA 101 standards was documented as a deficiency, specifically noting the non-compliance with the delayed egress locking arrangements.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. **K222 Egress Doors** Immediate Corrective Action: On 4/29/2025, an emergency purchase order was submitted and service request scheduled for vendor RF Technology to provide service to the egress door located on the west unit adjacent to the Coconut dining room. On 4/30/2025 RF Technology Inc. field service technician repaired the egress door. The door is equipped with delayed egress locking arrangements in accordance with NFPA 101. Identification of other residents potentially affected: All residents have the potential to be affected; however, based on inspection no residents were affected by this deficiency. All egress doors were inspected throughout the units to ensure compliance with NFPA 101 standards. No other egress doors were identified out of compliance. Measures: Director of Property Management and Maintenance team members were re-educated on conducting weekly egress door inspection and document on preventative maintenance sheet and report any non-functioning doors to supervisor immediately. Doors must be equipped with delay egress locking arrangements in accordance with NFPA 101. Monitoring: The Director of Property Management and Maintenance Assistants will complete weekly audits for 4 weeks and then monthly x two months to ensure compliance with NFPA 101 standards. Director of Property management will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 3 months or until committee determines substantial compliance.
HVAC System Deficiency in Soiled Utility Rooms
Penalty
Summary
The facility failed to maintain its Heating, Ventilation, and Air Conditioning (HVAC) system in accordance with NFPA 101 standards. During a facility tour conducted on April 29, 2025, between 1:15 PM and 2:45 PM, it was observed that the exhaust fans in the soiled utility holding rooms located in both the east wing of Pineapple Trail and the west wing of Lakeshore were not operational. These findings were made in the presence of the Director of Property Management. An interview with the Administrator and the Director of Property Management was conducted concurrently with the observations, during which they acknowledged the deficiencies. The findings were reviewed with both the Administrator and the Director of Property Management at the exit meeting on the same day at 3:00 PM. The report cites specific sections of NFPA 101 and NFPA 99 that were not adhered to, indicating a failure to comply with the required standards for HVAC maintenance.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. K521 HVAC Immediate Corrective Action: On 4/29/2025, HVAC technician assessed the exhaust fans immediately. A HVAC vendor was contracted to replace the two exhaust fans in soiled utility rooms. Identification of other residents potentially affected: All residents have the potential to be affected; however, based on inspection no residents were affected by this deficiency. HVAC system throughout the units were inspected to ensure compliance with NFPA 101 (2012 edition) and NFPA 99 (2012 edition) standards. No other HVAC system was identified out of compliance. Measures: Director of Property management and Maintenance assistance were re-educated on maintaining HVAC system by ensuring exhaust fans are inspected weekly, documented on preventative maintenance sheet and report any non-functioning HVAC system to supervisor immediately. Exhaust fans in biohazard rooms are required to be functioning to ensure ventilation to manage airborne particles and prevent contamination. Monitoring: The Director of Maintenance and Maintenance Assistants will complete weekly audits for 4 weeks and then monthly x two months to ensure in compliance with NFPA 101 (2012 edition) and NFPA 99 (2012 edition) standards. Director of Maintenance will report the findings to the Quality Assurance Performance improvement Committee Monthly X 3 months or until the committee determines substantial compliance.
Failure to Maintain Essential Electrical System Documentation
Penalty
Summary
The facility failed to maintain and test their Essential Electrical System (EES) in accordance with NFPA 99 standards. During a record review conducted on April 29, 2025, between 10:00 AM and 1:00 PM, it was found that there was no documentation available for two of the generator's monthly conductance tests. This lack of documentation was identified during a review with the Director of Property Management. The absence of these records indicates a failure to comply with the required maintenance and testing protocols for the facility's emergency power systems. An interview with the Administrator and the Director of Property Management confirmed the findings, and they acknowledged the deficiency. The review highlighted that the facility did not have the necessary records to demonstrate compliance with the NFPA 99 and NFPA 110 standards, which require regular testing and maintenance of generator sets and associated equipment. The findings were discussed with the facility's management at the exit meeting on the same day.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. K918 Electrical Systems- Essential Electric System Maintenance and Testing Immediate Corrective Action: On 4/30/2025, an Ancel BST500 electronic battery tester was purchased to test the generator battery. Identification of other residents potentially affected: All residents have the potential to be affected; however, based on inspection no residents were affected by this deficiency. No other generator was identified out of compliance. Measures: On 04/29/2025 the Director of Property management and maintenance assistance were re-educated on ensuring the generator battery tests are completed monthly by using the electronic battery tester and to record the conductance measurement on the log. On 5/07/2025, TAW Service Representative provided training and education to Director of Property management and maintenance assistance on using the electronic battery system tester to conduct cold cranking amps conductance test and documenting information on the monthly generator test log. Monitoring: The Director of Maintenance and Maintenance Assistants will complete weekly audits for 4 weeks and then monthly x two months to ensure compliance with NFPA 99 (2012 edition) and NFPA 110 (2010 Edition) standards. The Director of Maintenance will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 3 months or until the committee determines substantial compliance.
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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