Abbey Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Petersburg, Florida.
- Location
- 7101 Dr Martin Luther King Jr St N, Saint Petersburg, Florida 33702
- CMS Provider Number
- 105749
- Inspections on file
- 27
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Abbey Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Cold lunch items were not consistently held at safe temperatures during meal service observation, with a turkey croissant and puree turkey measuring above the required 41 degrees F while the DM confirmed the items were ready for resident consumption. In separate observations, kitchen staff handling food did not perform proper hand hygiene: one staff member touched exposed food and her chin without washing, and another touched food and then self-contacted clothing and skin without washing. The DM confirmed staff had been trained on hand hygiene and glove use, but the observed practices did not follow those standards.
A facility failed to maintain resident dignity during room care, communication, and meal service. One resident was left lying in tobacco saliva and debris with the call light out of reach, an LPN repeatedly told another resident to speak English, and a resident was briefly tapped on the buttocks in the dining room. Other residents were seated away from tables, served last, or assisted with meals while staff stood over them, and staff said residents needing feeding help often waited until last because of limited staffing.
Homelike Environment Not Maintained on Secured Unit: Surveyors observed 15 resident rooms on the secured unit with bare walls, minimal decor, no personal touches, and sparse common areas with non-inviting seating. A family representative said the unit was not very home like, and the NHA and DON acknowledged the area needed more items to make it feel more homelike, with the DON noting they were waiting for budget approval.
The facility failed to provide enough nursing staff to meet resident needs and to ensure a licensed nurse was in charge on each shift. Two cognitively intact residents reported that evening meds were late because one nurse was covering about 40 residents, and MAR review confirmed delayed administration of scheduled meds and repeat oxycodone doses. Resident council members reported call lights could take 1 to 2 hours to answer and that residents had waited up to 2 hours for bathroom help and incontinence care. An LPN on the 100 hallway and another LPN on the 200 hallway described heavy workloads, late starts, and limited support, while the staffing coordinator stated the facility needed more staff.
Staff failed to follow infection control practices during meal service and contact precautions. Residents on the secure unit were served meals without being offered hand hygiene, an RN and CNA passed trays without hand hygiene, and one CNA handled food with bare hands. In a room under contact precautions, a CNA removed gloves without hand hygiene and entered without a gown, despite staff stating that hand hygiene and gown/glove use were required.
Surveyors found that the facility failed to follow care plan interventions for two residents: one who used a scoop plate for eating and another who required a call light within reach. A resident with CVA-related hemiparesis, dysphagia, and dementia was repeatedly served meals with the high side of the scoop plate positioned away from him, causing food to be scraped off the plate, while staff did not adjust the plate and the meal ticket lacked instructions on proper positioning. Another cognitively intact resident with multiple neuropsychiatric diagnoses and an ADL self-care deficit was observed several times in bed with her call light on the floor or clipped to the back or top of her pillow, out of reach, despite a care plan requiring the call bell and call light to be kept within reach in her room and bathroom.
A resident with cognitive impairment and psychiatric diagnoses alleged that a CNA slapped him while he was being taken to the shower room after vomiting. Staff heard a loud smack and elevated voices, but the resident was then left alone in the shower room with the CNA, and no nurse assessed him for possible marks or skin changes after the allegation. The AD reported the resident was being handled roughly, while the CNA denied abuse and said the resident had a history of accusing staff of hitting him.
PASARR screening was not completed correctly for three residents with qualifying mental health diagnoses. One resident had no Level I PASARR before admission and no Level II request after diagnoses including schizoaffective disorder, bipolar disorder, and anxiety. Two other residents had Level I PASARRs showing mental illness and, in one case, intellectual disability/serious mental illness, but no Level II PASARR evaluations were submitted. The SSD stated the Level I screens were incorrect and that Level II requests were delayed pending completion of Level I screens and psychiatry notes.
Delayed care plan revision for resident behaviors. A resident with cognitive impairment, schizophrenia, psychosis, anxiety, and a history of TBI repeatedly yelled, accused staff and residents of hitting him, and engaged in self-injurious behaviors such as biting himself and picking at scabs. During one incident, staff heard a loud smack and the resident alleged he had been slapped, but he was not assessed for marks or skin changes, and staff later confirmed the behavior care plan had not been initiated until much later despite the behaviors being known to multiple staff members.
Two residents did not receive meal assistance despite documented needs for help with eating. One resident with severe cognitive impairment, hemiplegia, dementia, and malnutrition was observed trying to scoop food and dropping it on the table, while another resident with severe cognitive impairment and dependence for eating was observed feeding herself without assistance. Care plans identified assisted dining or dependent assist for eating, and CNAs and the DON acknowledged that residents who need help with meals should be assisted.
A resident with severe cognitive impairment and a BIMS score of 0 had change-in-condition documentation listing the resident as the responsible party or notifying the resident’s own RP, despite records showing family contacts and staff confirming the resident could not make decisions for himself. The DON and SSD acknowledged the resident’s impaired cognition and that family communication was expected for updates, labs, and condition changes, but the documentation did not reflect proper notification of the resident representative.
Failure to monitor and report abnormal catheter urine. A resident with a nephrostomy catheter and diagnoses including anoxic brain damage and obstructive/reflux uropathy had dark red, cloudy, red, and amber urine observed in the catheter bag. The care plan required staff to observe, document, and report signs of UTI and catheter complications, but a CNA did not report the red urine because it was believed to be normal, an LPN was unaware of the change, and the EMR showed no physician follow-up or documentation of the abnormal urine color.
Oxygen therapy was not provided per physician order for a resident with anoxic brain damage and chronic respiratory failure who received oxygen via trach. An observation showed the oxygen concentrator set at 9 LPM instead of the ordered 7 LPM, and staff stated the nurse was responsible for setting and maintaining the concentrator according to the order. The ADON acknowledged the incorrect setting and said nurses should check oxygen settings during care and med passes.
Inadequate behavioral documentation, supervision, and staffing on the secured unit. A resident with TBI, schizophrenia, depression, anxiety, and psychosis was observed yelling that a CNA hit him, but the nurse did not assess him for marks and the resident was left alone with the CNA in the shower room. His chart showed repeated behaviors such as yelling, accusations, agitation, and self-injury, yet the behavior task documented no behaviors observed. Two other residents were observed with limited supervision during meals, including one resident who was dependent for eating but was seen feeding herself, while staff reported the unit was short an aide and lunch care was challenging.
Pharmacy recommendations to stop unnecessary lithium level labs were not fully carried out for a resident whose lithium had been discontinued. The consulting pharmacist noted the resident was still getting monthly lithium labs despite no active order for the medication, and repeated the recommendation after the lab continued. The DON said there was confusion because two lithium lab orders existed, one monthly and one every 3 months, and both were later discontinued.
A resident with a suprapubic catheter missed outside ophthalmology and urology appointments. The resident said he needed eye care for his vision and monthly urology follow-up, but the transportation log and appointment binder had no entries for him, and records noted a missed urology visit due to transport issues. Staff interviews showed the facility relied on nursing, medical records, and MAR-based coordination, but the process did not result in the resident’s appointments being arranged and completed as expected.
A facility failed to inform a physician of critical lab values for a resident receiving Vancomycin, leading to ICU admission for renal dialysis due to Vancomycin toxicity. Nursing staff did not follow protocol to notify the physician or DON, and lab results were not reviewed or communicated properly. Additionally, another resident with a history of substance abuse and elopement left the facility unnoticed, highlighting inadequate supervision and risk assessment.
The facility failed to ensure staff donned appropriate PPE while caring for residents under Enhanced Barrier and Transmission Based Precautions. A CNA did not wear a gown while providing care to a resident with a gastrostomy tube, and failed to perform proper hand hygiene. The CNA was unaware of the specific precautions required and did not see the necessary signage. Additionally, the CNA had long artificial fingernails, against facility policy. The facility's policies on isolation precautions and personal hygiene were not adhered to, leading to the deficiency.
Cold Food Temperature Control and Hand Hygiene Lapses
Penalty
Summary
The facility failed to ensure planned cold lunch items were held at or below the required temperature during meal service observation on 4/1/2026. The posted lunch menu included turkey croissant, macaroni salad, relish salad, pudding, and an alternate of beef stew. The Dietary Manager confirmed the primary lunch items were to be served cold and should be below 41 degrees F, and staff stated the items had been prepared and were ready for resident consumption. During temperature demonstrations, the turkey croissant with cheese reached 47.9 degrees F and later 46.9 degrees F, and the puree consistency turkey reached 44.4 degrees F and later 44.6 degrees F. The macaroni salad and mechanical soft sandwich reached 40 degrees F, and the turkey croissant later reached 40.6 degrees F, but the puree turkey did not meet the required holding temperature. The Dietary Manager stated the cold items were normally prepared and placed in the walk-in refrigerator for about an hour before meal service and then set in ice to maintain temperature, with temperatures documented on a food temperature log. On the day of observation, he confirmed the process had been completed, but some items did not get below 41 degrees F. Because two food items did not meet the minimum holding requirement, the Dietary Manager stated the items would be taken off the service table and placed in the walk-in freezer longer, and he confirmed the lunch meal would be served late due to the delay. The facility also failed to promote good hand hygiene during food handling. On 4/1/2026, Staff A conducted a food temperature demonstration while wearing one glove on the left hand and no glove on the right hand, and was observed touching exposed food items and the side of her chin with her right hand without washing her hands afterward. On 4/2/2026, Staff C was observed at the steam table without washing her hands before the demonstration, touching food items with her bare right hand, and then touching her pants, left hand, and arm without washing during the observation. The Dietary Manager later confirmed staff had been trained on hand hygiene and should wash hands after touching self, food items, or potentially contaminated surfaces, and that hands must be washed before wearing gloves and between changing gloves.
Failure to Maintain Resident Dignity During Care and Meals
Penalty
Summary
The facility failed to promote and maintain dignity for residents during activities, meal services, and while residents were in their rooms. One resident was observed lying in bed with the call light cord/button out of reach and with dark saliva and brown matter from chewing tobacco on the resident’s mouth, bedding, mattress, bed frame, and nearby trash can. The resident stated the tobacco spit had been on the bed since the day before and that the call light was out of reach when the resident wanted staff to clean it up. The resident’s record showed diagnoses including encephalopathy, dysphagia, dementia, lack of coordination, depression, schizoaffective disorder, mood disorder, and anxiety, and the DON acknowledged staff should have cleaned the area and that the resident should not have remained in it for long periods of time. During another observation, a resident was heard speaking in a language of choice in the hallway, and an LPN repeatedly redirected the resident to speak English, stating, "Speak English." In the dining room, another resident was observed standing between tables and chairs while an LPN briefly tapped the resident on the buttocks. A different resident was observed seated alone away from other residents near a sink without a table while waiting for a meal and was served last; on another day, that resident remained in bed while other residents were served and assisted, then was brought to the dining room after others had already eaten. On a later observation, the same resident was moved away from a table to a chair without a table and was assisted with the meal after the other residents had been served. Additional observations showed residents needing feeding assistance were handled in ways that did not maintain dignity. One resident was assisted with a meal while staff stood next to the resident, and another resident was overheard being described by staff as "a feeder" who needed help eating. Staff interviews reflected that residents needing meal assistance often had to wait until last because there were only two aides and a nurse on the floor. The facility policy stated that each resident has a dignified existence and the right to be free of interference, coercion, discrimination, and reprisal, and the NHA stated dignity should always be held, residents should be knocked on for, covered, and addressed by preferred names.
Homelike Environment Not Maintained on Secured Unit
Penalty
Summary
The facility failed to provide a homelike environment in 15 resident rooms (#1 through #15) on the secured unit (300 Hall). During multiple tours of the unit from 03/30/3026 through 04/02/2026, surveyors observed plain hallways with minimal decor, no personal touches or affects throughout the physical environment, bare resident rooms with no personal effects, and common areas that were sparse with little decoration and non-inviting seating. The overall atmosphere was described as lacking warmth, comfort, and familiar features. Residents on the secured unit could not be interviewed because of severe cognitive impairments. A family representative stated that the place could use some personal touches and was not very home like. The NHA confirmed the secured unit could use more items to make it feel more homelike and stated the walls were bare. The DON stated the facility was working on getting items that were more interactive and could not be removed from the walls, but said they had to wait for budget approval. Review of the facility policy titled Physical Environment, effective August 2024, stated that a safe, clean, comfortable, and home life environment is provided for each resident, allowing the use of personal belongings to the greatest extent possible.
Insufficient Nursing Staffing Caused Late Medications and Delayed Call Light Response
Penalty
Summary
The facility failed to provide adequate nursing staff to meet resident needs and to have a licensed nurse in charge on each shift. During the evening medication pass, Resident #100, who was cognitively intact with diagnoses including major depressive disorder, opioid dependence, chronic pain syndrome, chronic systolic heart failure, and hypertension, reported that staffing was low and that only two nurses were covering the 100 hallway instead of the usual three. The resident stated the nurse was rushing and had close to 40 residents to medicate. Record review showed scheduled medications, including pregabalin and oxycodone, were administered late on 3/29/2026, with the 5:00 p.m. doses given at 7:06 p.m. and another oxycodone dose given at 8:30 p.m. Resident #94, who was cognitively intact and had diagnoses including COPD with exacerbation, hypertension, major depressive disorder, generalized anxiety disorder, and dislocation of an internal left hip prosthesis, also reported that evening medications were late because the nurse assigned to the hallway had 40 residents to administer medications to. Her medication record showed that scheduled 5:00 p.m. doses of baclofen, ipratropium-albuterol, buspirone, and oxycodone-acetaminophen were administered at 7:40 p.m., and the next oxycodone dose was given at 8:38 p.m. Staff Y, an LPN assigned to the 100 hallway, stated he and one other nurse covered the entire hallway, that he did not get a bathroom break or a break in general on Friday, and that the same situation occurred on Sunday when normally there are three nurses on the hallway. He stated he knew residents were unhappy with their care and questioned whether a good nurse could realistically get the work done. Resident council members reported that the 7 a.m.-3 p.m. and midnight shifts needed extra help and that call lights could take one to two hours to be answered. They also reported residents had been left in the bathroom waiting for assistance for up to two hours and had waited up to two hours for incontinence care. Staff O, an LPN on the 200 hallway, stated she had 18 residents, including 4 with tracheostomies, 6 with gastrostomy tubes, and 3 wound dressings, and that she had a late start because the night shift nurse was still providing care and overwhelmed by workload. The staffing coordinator stated she was new to the position, used PPD and census to determine staffing, had not used the facility assessment to staff the building, and said, "We need more staff."
Infection Control Failures During Meal Service and Contact Precautions
Penalty
Summary
The facility failed to follow infection prevention and control practices related to hand hygiene during meal service and transmission-based precautions. On the secure unit (300 hall), residents were observed sitting in the dining room while staff began passing meal trays without offering hand hygiene before meals on three separate observations. During one meal service, an RN moved glasses from the top of her head to her face, lifted lids off the food on the meal cart, and passed trays without performing hand hygiene. A CNA also passed meal trays to multiple residents without hand hygiene in between and, while assisting a resident with a meal, grabbed a food item with bare hands and began cutting it up. Staff interviews stated that hand hygiene should be used in between residents and that residents should be offered hand hygiene before meals, but paper towel dispensers had been removed from rooms on the 300 unit, making hand hygiene difficult for staff to perform and dry properly. The facility also failed to follow contact precautions in room [ROOM NUMBER]. A CNA was observed exiting the room with gloves, removing and disposing of the gloves at the nurse’s station without hand hygiene, then later entering the room without a gown and reaching outside the room with a gloved hand to obtain a gown. The CNA stated that residents in the 200 unit were under contact precautions and that hand hygiene should be performed before and after care, along with gown and glove use before entering the room. An LPN stated that contact precautions required hand hygiene before entering and upon exit, along with gloves, gown, and mask. The facility policy on hand washing and glove use stated that hands must be washed before wearing gloves and dried using disposable paper towels, and the isolation precautions guidance stated that contact precautions require hand hygiene and gown use when caring for residents under contact precautions.
Failure to Implement Care Plan Interventions for Adaptive Eating Equipment and Call Light Access
Penalty
Summary
The deficiency involves the facility’s failure to implement care plan interventions related to adaptive eating equipment for one resident. During multiple lunch observations in the main dining room, a resident with a history of cerebral infarction, seizures, dementia, dysphagia, lack of coordination, muscle wasting, and hemiparesis with left-side neglect was served meals using a scoop plate. On at least two observed occasions, the high side of the scoop plate was positioned away from the resident, even though he scooped food inward toward himself. As a result, food was scraped off the plate onto the table and his lap. Staff present in the dining room did not adjust the plate to accommodate his scooping pattern, and the meal ticket only indicated “use of scoop plate” without specifying how it should be positioned, despite the resident’s care plan and therapy input indicating the need for adaptive equipment to support nutrition and functional limitations. The deficiency also includes the facility’s failure to ensure that a resident’s call light was within reach, as required by her care plan. Over several observations, the resident was repeatedly found in bed with the call light cord either on the floor behind the bed or clipped to the back or top of her pillow, out of her reach. On one occasion, she was lying in bed with dark-colored saliva and brown matter on her upper buttocks, mattress surface, bed frame, and nearby trash can, and she could not reach the call light. On subsequent days, the call light remained positioned where she could not access it, and she reported that staff routinely clipped it to the top of her pillow and that this happened all the time. The resident with the inaccessible call light had diagnoses including encephalopathy, dysphagia, dementia, lack of coordination, depression, schizoaffective disorder, mood disorder, and anxiety, but her most recent MDS showed she was cognitively intact with a BIMS score of 15 and required setup/cleanup assistance for personal hygiene, toileting, and toilet transfer. Her care plan included interventions specifying that the call bell should be within reach in her room, bathroom, and shower room, and that environmental adaptations should include keeping the call light within reach due to her risk for falls or fall-related injuries. Despite these documented interventions, staff practices resulted in the call light being placed out of her reach on multiple observed occasions.
Failure to Separate Resident After Alleged Physical Abuse
Penalty
Summary
The facility failed to implement its abuse policy after an allegation of physical abuse involving one resident. On 3/30/26, while the Activities Director was approaching the closed shower room door on the secured 300 unit, she heard elevated voices, a loud smack, and the resident state, "He slapped me." When the door was opened, the resident was observed in a wheelchair with a pink substance on his shirt and pants, and he said the CNA slapped him. The CNA denied hitting the resident and said the resident slapped himself. The resident was then escorted into the shower room with the CNA, and the nurse walked away; the resident was left alone with the CNA in the shower room after the allegation was made. The resident involved had an admission date of 7/17/25 and diagnoses including traumatic brain injury, schizophrenia, psychotic disorder, mood disorder, anxiety, depression, and cerebral infarction. His record also showed a BIMS score of 8/15, indicating moderate cognitive impairment. The resident’s care plan included that he accuses others of hitting him when there is no one around, and the facility’s behavior task showed daily documentation of no behaviors observed. However, staff interviews described the resident as frequently yelling and accusing staff or residents of hitting him, while the Activities Director stated she had not previously observed that type of interaction between the resident and the CNA. The Activities Director reported that she heard the resident yelling that he was hit and saw the CNA pushing him in a rough and aggressive manner. She said she tried to get the resident away from the CNA because the situation felt hostile, and she reported the allegation to the NHA/Risk Manager. The NHA and DON later confirmed that, for an allegation of abuse between a staff member and a resident, the resident should have been separated from the staff member and made safe, and they confirmed the resident should not have gone back into the shower room with the CNA. The resident was not assessed by a nurse for markings or skin changes after the allegation, and the shower room door was closed with the CNA and resident inside without other staff present.
PASARR Screening Not Completed for Residents With Mental Illness and Related Conditions
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed correctly for three residents with qualifying psychiatric and related diagnoses. Resident #10 was admitted with diagnoses including schizoaffective disorder, bipolar type, depressive disorder, mood disorder, psychoactive substance abuse, antisocial personality disorder, generalized anxiety disorder, epilepsy, and alcohol use, but the record showed no Level I PASARR completed prior to admission and no Level II PASARR submitted after the qualifying diagnoses were identified. Resident #34 was admitted with diagnoses including dementia with behavioral disturbance, mood disorder due to a known physiological condition with mixed features, other psychotic disorder, major depressive disorder, generalized anxiety disorder, anxiety disorder, insomnia, and alcohol abuse. The Level I PASARR dated 1/30/26 identified multiple mental illnesses and showed yes responses in Section II, with Section IV indicating serious mental illness and intellectual disability, yet no request for a Level II PASARR evaluation was submitted. Resident #62 was admitted with diagnoses including unspecified dementia with anxiety and agitation, mood disorder due to a known physiological condition, major depressive disorder, other persistent mood disorders, pseudobulbar affect, cannabis use, bipolar disorder, anxiety disorder, and insomnia. The Level I PASARR dated 1/30/26 identified mental illness and Section IV indicated serious mental illness, but no Level II PASARR evaluation was requested. During interview, the SSD stated the Level I PASARRs were incorrect, that she completed the Level I screens for multiple halls, and that Level II PASARRs would be worked on after the Level I screens; she also stated she could not submit Level II evaluations without the DON and that Level II is requested when there are related conditions.
Delayed Care Plan Revision for Resident Behaviors
Penalty
Summary
The facility failed to revise Resident #80’s care plan in a timely manner related to behaviors. Resident #80 was admitted on 7/17/25 with diagnoses including traumatic brain injury, recurrent depressive disorders, schizophrenia, persistent mood disorder, psychotic disorder with delusions due to a known physiological condition, generalized anxiety disorder, unspecified psychosis, and cerebral infarction. The resident’s quarterly MDS showed a BIMS score of 8 out of 15, indicating moderate cognitive impairment, and the behavior section marked that physical, verbal, and other behavioral symptoms were not exhibited. On 3/30/26, staff observed an incident in the shower room on the secured unit in which elevated voices were heard, followed by a loud smack and the resident stating, “Ow, he slapped me.” The resident was observed in a wheelchair with a pink substance on his shirt and pants. Staff F, CNA denied slapping the resident and stated the resident slapped himself. The Activities Director asked if the resident wanted assistance from an LPN, and Staff J, LPN responded that she had a care plan for vomiting on himself. The resident said he wanted the Activities Director to stay with him, but Staff J, LPN turned him around in the wheelchair, escorted him into the shower room, and left him with Staff F, CNA. The resident was not assessed by the nurse for markings or skin changes after the allegation, and the shower room door was closed with only the CNA and resident inside. Record review and staff interviews showed the resident had a pattern of yelling, accusing staff and residents of hitting him, and engaging in self-injurious behaviors such as biting himself, scratching himself, picking at scabs, and scraping his hands against the wheelchair. Staff members stated these behaviors were known and occurred repeatedly, but Staff J, LPN confirmed the care plan for the behavior of accusing staff and residents of hitting him was not initiated until the day before the interview. The DON stated nursing staff should have documented the behavior and the care plan needed to be updated when the behavior occurred. The facility policy required the interdisciplinary care plan to address resident needs, including behavioral management, and to be updated based on current diagnoses, interventions, and changes in condition.
Failure to Assist Residents With Meals
Penalty
Summary
The facility failed to provide assistance with meals for two residents who had documented needs for help with eating. Resident #34, admitted with diagnoses including cerebral infarction sequelae, left-sided hemiplegia and hemiparesis, protein-calorie malnutrition, dementia, muscle wasting, generalized weakness, anxiety, mood disorder, and psychotic disorder, was observed in the secure unit dining room attempting to scoop food from his plate and dropping it onto the table. On a later observation, the resident was again seen scooping food from his plate and feeding himself. His admission record showed severe cognitive impairment with a BIMS score of 02 out of 15, and his care plan identified a nutritional problem with an intervention for assisted dining and documentation of the amount of assistance needed with meals. Resident #61, admitted with diagnoses including metabolic encephalopathy, dementia, major depressive disorder, altered mental status, and convulsions, was observed in the secure unit dining room feeding herself without assistance. Her quarterly MDS showed severe cognitive impairment with a BIMS score of 0 out of 15, and Section GG indicated she was dependent for eating, meaning the helper does all of the effort or two or more helpers are required. Her care plan also identified an ADL self-care performance deficit and listed eating as dependent assist of 1. During interviews, CNAs stated they would assist residents with meals if they saw they needed help, and one CNA stated Resident #61 needed assistance with meals and that she had helped her that day. The DON stated staff should be helping all residents who need assistance with their meals.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to ensure a notification of change was completed for a resident with severe cognitive impairment. Resident #129 had an admission record showing diagnoses including unspecified intracranial injury with loss of consciousness, unspecified sequelae of cerebrovascular disease, acute and chronic respiratory failure with hypoxia, encephalopathy, and tracheostomy status. The resident’s MDS and BIMS evaluations showed a BIMS score of 0, indicating severe cognitive impairment, yet the admission record listed the resident as the responsible party and identified two family members as emergency contacts. Record review showed change in condition evaluations documenting notifications to “SELF” or the resident’s own responsible party, including a 3/11/26 change in condition evaluation and a 3/28/26 change in condition evaluation. Progress notes also documented communication with the MD, ARNP, pharmacy, and “Resident own RP.” During interviews, the SSD and DON confirmed the resident had a BIMS of zero and could not make decisions for himself due to cognition, and the DON stated the expectation would be to call the family member for lab results, changes in condition, and updates. The facility policy required notification of the resident, resident representative, or legal representative when there was a significant change in condition, but the documentation reflected the resident as his own responsible party despite severe cognitive impairment.
Failure to Monitor and Report Abnormal Catheter Urine
Penalty
Summary
The facility did not ensure ongoing monitoring for changes in condition related to catheter use for one resident with a nephrostomy catheter. Resident #126 was admitted with diagnoses including anoxic brain damage and obstructive and reflux uropathy, and had an active order for a nephrostomy catheter with drainage every shift and as needed. The care plan identified the resident as having a urinary catheter with risk for infection and/or complications and directed staff to observe, document, and report signs and symptoms of UTI, including blood-tinged urine, cloudiness, no output, deepening urine color, fever, chills, altered mental status, and changes in behavior or eating patterns. Observations showed the resident’s catheter bag contained dark red and cloudy urine, and later red and amber urine. Staff O, an LPN, stated the physician should be notified if changes were observed in the resident’s output or color, but the EMR contained no documentation or follow-up with the physician regarding the observed urine changes. Staff P, a CNA, stated she observed red urine while providing morning care and draining the nephrostomy bag but did not report it because she believed it was normal. The ADON stated abnormal urine output would include a change in color and that the CNA should notify the nurse, who should assess the resident and notify the physician and family, but no documentation of abnormal urine output was provided.
Oxygen Therapy Not Provided Per Physician Order
Penalty
Summary
The facility did not ensure oxygen therapy was provided per physician orders for Resident #126. The resident was admitted with diagnoses including anoxic brain damage and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, and had a care plan focus for oxygen therapy related to oxygen via tracheostomy and oxygen dependence. The physician order active as of 04/02/2026 directed humidified oxygen per trach continuously, 7 liters every shift for shortness of breath, effective 03/26/2026. On 03/30/2026 at 2:21 PM, observation showed Resident #126's oxygen concentrator was set at 9 liters per minute instead of the ordered 7 liters. Staff O, an LPN, stated the nurse is responsible for setting and maintaining the oxygen concentrator according to the resident's orders. The ADON stated nurses should follow the orders in the electronic medical record and check the oxygen concentrator settings every time they provide care or pass medications, and acknowledged the photographic evidence showing the concentrator set at 9 liters per minute. The facility policy on Oxygen Therapy stated oxygen is provided based on physician's orders and requires applying the device with the appropriate liter flow.
Inadequate behavioral documentation, supervision, and staffing on secured unit
Penalty
Summary
The facility failed to ensure nursing staff were competent to meet the behavioral health needs of residents on the secured unit. During observation, Resident #80 was heard yelling from a closed shower room after Staff F, CNA, was observed behind him in a wheelchair with a pink substance on his clothing. Resident #80 stated that Staff F slapped him, while Staff F denied hitting him and said the resident had slapped himself. The Activities Director observed the resident being pushed in a rough manner and aggressively by Staff F, and the resident was not assessed by the nurse for markings or skin changes that could indicate a slap or hit. Staff J, LPN briefly came to the shower room, but the resident and CNA were left together in the shower room without other staff present. The resident continued yelling that he had been hit. Resident #80 had diagnoses including traumatic brain injury, schizophrenia, psychotic disorder, major depressive disorder, generalized anxiety disorder, and cerebral infarction. His record showed an order for side effect monitoring every shift, and his care plan included behavioral interventions such as documenting episodes of behavior and reviewing their effectiveness. However, the behavior task for the last 30 days showed daily documentation of no behaviors observed. The record also showed multiple notes describing yelling, accusations, agitation, and impulsive verbalizations, and staff interviews confirmed that he frequently accused staff and residents of hitting him, yelled, picked at and ate his scabs, and bit himself. The DON stated that behaviors such as agitation, hitting, kicking, or biting could be documented in behavior monitoring or progress notes, and that documentation was important for psychiatry to know when evaluating medications and side effects. The deficiency also involved supervision and staffing on the secured unit. During observations, Resident #62 was seen in a room with the door closed, moving around slowly and opening drawers, while staff were observed in the dining room and at the nurse’s station. Resident #34 was observed in the dining room scooping food off his plate and dropping it on the table, and Resident #61 was observed feeding herself even though her MDS showed she was dependent for eating and her care plan indicated she required assistance. Staff interviews stated that the unit normally had three aides and one nurse, but on the day of observation there were only two aides and a nurse because one aide had been sent home, making lunch time challenging because residents needing assistance had to wait while trays were passed. Staff also stated that behaviors were not documented if they were considered usual for the resident, and that only certain behaviors such as resident-to-resident or sexual behaviors were documented.
Pharmacy Lab Monitoring Recommendations Not Completed
Penalty
Summary
The facility did not ensure pharmacy recommendations related to lab monitoring were completed for one resident. Resident #13 had a history that included other persistent mood disorders, undifferentiated schizophrenia, generalized anxiety disorder, and unspecified psychosis not due to a substance or known physiological condition. The resident had been prescribed Lithium Carbonate 300 mg daily for mood disorder, which was ordered on 6/14/2025 and discontinued on 12/12/2025. Psychiatric progress notes on 12/12/2025 stated the resident should continue lithium 300 mg daily because the last lithium level was very low and the resident had been stable, with consideration of restarting if mood destabilized. The consulting pharmacist completed monthly medication regimen reviews and documented that the resident was still receiving monthly lithium level labs even though the medication had been discontinued or was not reordered. On 01/08/2026, the pharmacist recommended discontinuing the lithium level lab order, and the recommendation was marked "Done" in the follow-through column. A later medication regimen review again noted that the resident no longer received drug therapy requiring lab monitoring and recommended discontinuing lithium levels, with the pharmacist stating she repeated the recommendation because the lab continued. Lab results for lithium remained low on multiple dates, and the DON acknowledged there had been confusion because two lithium lab orders existed, one monthly and one every three months. Psychiatric progress notes on 3/13/2026 documented that the resident remained stable and cooperative with care, with no behavioral disturbances, anxiety, or agitation reported.
Missed Outside Appointments Due to Scheduling and Transportation Failures
Penalty
Summary
The facility did not ensure outside physician appointments were arranged and scheduled in a timely manner for one resident who had a suprapubic catheter and reported needing monthly urology follow-up, as well as an ophthalmology appointment for vision concerns. During interview, the resident stated he had missed an outpatient ophthalmology appointment and also missed his monthly urologist appointment for March. An appointment card showed an ophthalmology visit scheduled for 01/16/2026, and the resident stated he needed to be seen by his eye doctor for his vision. Record review showed the resident declined the scheduled ophthalmology appointment on 01/16/2026, after which a new appointment was arranged for 02/02/2026. Progress notes also showed the resident returned from a urology appointment on 01/12/2026 with a follow-up scheduled for 02/02/2026, and later a nurse practitioner note stated the resident missed a recent urology appointment due to transport issues. Interviews with the RN/UM, ADON, and DON showed the facility used a transportation binder, nursing staff, medical records staff, and MAR entries to coordinate appointments and transportation, but the transportation log for January, February, and March had no entries for the resident and the March binder had no appointment entry for him.
Neglect in Lab Result Communication and Resident Supervision
Penalty
Summary
The facility failed to protect a resident from neglect by not informing the attending physician of critical lab values in a timely manner and continuing to administer Vancomycin despite these critical results. The resident, who had a history of chronic kidney disease and other serious health conditions, was receiving Vancomycin for an infection. Critical lab results indicating Vancomycin toxicity and elevated potassium levels were acknowledged by nursing staff but not communicated to the physician or acted upon appropriately. This led to the resident being admitted to the Intensive Care Unit for renal dialysis due to acute kidney injury and Vancomycin toxicity. The report details a breakdown in communication and protocol adherence among the nursing staff. Despite receiving critical lab results, the responsible nurses did not notify the physician or the Director of Nursing as required by the facility's policy. The Unit Manager and other staff members failed to review the lab results properly, and the results were not communicated to the pharmacy for appropriate dosing adjustments. The attending physician was not informed of the critical lab values, which could have prompted immediate medical intervention. Additionally, the facility failed to provide adequate supervision and a secure environment for another resident with a history of substance abuse and leaving medical facilities against medical advice. This resident was able to leave the facility unnoticed, despite having an intravenous site, and was later found in a hospital. The facility's failure to assess the resident's risk for elopement and provide necessary supervision contributed to this incident.
Inadequate PPE Use and Infection Control in LTC Facility
Penalty
Summary
The facility failed to implement an effective Infection Control and Prevention program, as evidenced by staff not donning appropriate personal protective equipment (PPE) while caring for residents under Enhanced Barrier Precautions and Transmission Based Precautions. Specifically, a Certified Nursing Assistant (CNA) did not wear a gown while providing care to a resident with a gastrostomy tube, who was under Enhanced Barrier Precautions. The CNA also failed to perform proper hand hygiene after exiting the resident's room and before interacting with another resident. The report highlights that Resident #5, who had a gastrostomy tube and was on Enhanced Barrier Precautions, did not receive care in accordance with the required infection control measures. The CNA entered the room without a gown, only wearing gloves, and did not follow the protocol of donning a gown and gloves before providing care. Additionally, the CNA was unaware of the specific precautions required for residents with certain medical devices, such as a g-tube, and did not see the necessary signage indicating the precautions. Furthermore, the facility's Infection Control Preventionist and Assistant Director of Nursing (ICP/ADON) confirmed that staff should be aware of the PPE requirements based on door signage and information received during reports. The report also noted that the CNA had long artificial fingernails, which is against the facility's policy due to infection control concerns. The facility's policies on isolation precautions and personal hygiene were not adhered to, contributing to the deficiency.
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Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
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