Ansley Cove Healthcare And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Maitland, Florida.
- Location
- 1301 W Maitland Blvd, Maitland, Florida 32751
- CMS Provider Number
- 105886
- Inspections on file
- 28
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 22 (3 serious)
Citation history
Health deficiencies cited at Ansley Cove Healthcare And Rehabilitation during CMS and state inspections, most recent first.
A resident who had lived in the facility for many years died while covered by Medicaid, with a set monthly income and personal needs allowance, and a monthly patient responsibility paid from a joint checking account by the spouse. After the resident’s death, the facility continued to draw the monthly patient responsibility from the joint account and did not refund the overpayment and remaining funds to the spouse within the required 30-day timeframe. Emails showed that the Business Office Manager notified corporate accounting of the death and requested removal from ACH, and that staff knew the spouse was requesting a refund and was owed more than initially thought. Over four months later, leadership confirmed that a refund of $1,905.35 was still owed and had not been processed, in violation of the facility’s own refund policy and federal requirements.
A resident who was totally dependent on staff for all care, including nutrition via g-tube and frequent repositioning, was not properly monitored or cared for during a shift. Staff failed to provide required assessments, did not check for responsiveness, and did not perform necessary care tasks. The resident was later found unresponsive, exhibiting signs of rigor mortis and a low core body temperature, indicating death had occurred hours before discovery. Documentation was inconsistent, and staff interviews revealed care was not provided as required.
A resident with severe cognitive impairment and multiple health conditions was found unresponsive and later determined by EMS and hospital staff to have been deceased for some time, exhibiting rigor mortis. Documentation and staff interviews revealed that required care was not provided during the evening shift, and there were conflicting accounts regarding the discovery and response to the resident's condition. Facility administration failed to conduct a thorough investigation, did not obtain statements from all involved staff or EMS, and delayed required reporting to the State Agency.
A resident with severe cognitive impairment and total dependence on staff did not receive required ADL care, repositioning, or timely assessments during a shift. Staff failed to recognize or respond to a change in condition, did not physically assess the resident for responsiveness, and inaccurately documented care. The resident was later found unresponsive and, according to EMS and hospital records, had been deceased for several hours prior to discovery, exhibiting rigor mortis and hypothermia. This failure to provide care and timely intervention resulted in Immediate Jeopardy.
A facility failed to conduct a QAPI meeting after a resident was found deceased with signs of rigor mortis, despite inconsistencies in staff documentation and an allegation that the assigned CNA did not provide care during a shift. The NHA, DON, and Medical Director were aware of the incident and discrepancies but did not bring the matter to QAPI for review.
Staff provided inconsistent and misleading statements about a resident's death, with conflicting documentation and witness accounts regarding care and the initiation of CPR. High-level personnel failed to ensure truthful reporting, and staff reported being pressured to provide false statements. Allegations of neglect and ethical violations were not reported to authorities, and the facility did not foster effective communication or protect staff from retaliation, resulting in an inadequate investigation of the resident's death.
A resident with a history of falls, cognitive impairment, and on multiple high-risk medications experienced several unwitnessed falls, including one resulting in a head injury, due to the facility's failure to timely identify and implement appropriate fall prevention interventions. Care plans were incomplete or delayed, fall risk assessments were inaccurate, and supervision was inadequate, leading to actual harm.
A resident with cognitive impairment, mobility deficits, and a history of falls did not receive timely or appropriate fall prevention interventions. Despite being on high-risk medications and having multiple risk factors, the care plan lacked a fall prevention focus for several weeks, and supervision was inconsistent. The resident experienced multiple falls, including one resulting in a head injury, due to inadequate implementation of the facility's fall prevention protocols.
The facility did not maintain an effective QAPI/QAA program, failing to identify and address repeated deficiencies or ensure complete monitoring documentation for corrective action plans. Despite previous enforcement actions for issues such as abuse, neglect, and accident hazards, the QAPI committee did not systematically monitor or document corrective actions, and frequent changes in the DON role contributed to a lack of sustained oversight.
The facility did not ensure the DON followed ethical and professional standards, as the DON backdated evaluations with incorrect documentation and lacked evidence of required education or competency training. Compliance program materials were not accessible to all staff, and key compliance documentation was missing from the DON's file.
A resident with moderate cognitive impairment and a history of falls did not have accurate or timely fall risk assessments or a fall prevention care plan due to backdated and incorrect documentation by the former DON and inaccurate MDS coding by the MDS Coordinator. Despite multiple unwitnessed falls and use of high-risk medications, the resident's risk scores were not updated, and individualized interventions were missing from the care plan.
A resident with cognitive and physical impairments, on blood thinner medication, experienced two unwitnessed falls in an LTC facility due to inadequate supervision by CNAs. The facility failed to initiate timely neurological checks or notify the physician after the second fall, despite the resident developing a hematoma. Insufficient staff education and supervision processes contributed to the neglect and harm experienced by the resident.
A resident with cognitive and physical impairments, on blood thinners, experienced two falls in the activity room due to inadequate supervision. Despite being a known fall risk, the resident was left unattended, resulting in a bruise and hematoma after the second fall, necessitating hospital transfer. The care plan was not updated to reflect the need for increased supervision, and interventions were insufficient.
The facility failed to maintain adequate staffing levels to meet the care needs of residents, many of whom required significant assistance. Observations and staff interviews revealed that CNAs were rushed, call light response times were delayed, and supervision for residents at risk for falls was insufficient. The facility's administration was reportedly unaware of the staffing issues, which were based on census numbers rather than actual care needs, leading to overwhelmed staff and compromised resident care.
A resident with severe cognitive impairment and on anticoagulant medication fell in a facility's activity room. The nurse assessed the resident but failed to promptly notify the physician or escalate the issue when the APRN did not respond. The physician discovered a hematoma during routine rounds the next day, highlighting a lapse in following the facility's notification protocol.
A resident at high risk for falls experienced two unwitnessed falls in the activity room due to inadequate supervision and failure to follow the facility's abuse and neglect policy. The DON did not consider the incidents as neglect, and the facility did not report them. The Administrator later acknowledged the lack of detail in the investigation and the need for more rigorous questioning.
The facility failed to provide adequate ADL care for three residents, including fingernail and oral care, and dressing. A resident with severe cognitive impairment had long, dirty fingernails, while another reported her nails had not been cut since admission. A third resident was observed with poor oral hygiene and soiled clothing. The facility's policy required regular grooming and hygiene services, but staff failed to adhere to these standards, resulting in inadequate care.
The facility failed to provide private access to telephones and internet for three residents, impacting their ability to communicate with family. Residents had to use public phones without privacy, and management did not formally address the issue, which arose from a service disconnection due to an unpaid balance. Staff confirmed the lack of communication and privacy, contrary to facility policy.
The facility failed to properly store and maintain sanitary conditions for food items in both the main kitchen and resident pantry. Observations revealed opened and undated food packages, expired items, and unsanitary conditions in the resident pantry's refrigerator. The Food and Nutrition Manager and a kitchen aide acknowledged the issues, highlighting lapses in food handling and cleanliness protocols.
The facility failed to update PASARR Level I Screens for two residents with new mental disorder diagnoses. One resident, diagnosed with dementia and major depressive disorder, did not have an updated PASARR despite being non-verbal and requiring assistance for daily activities. Another resident, diagnosed with bipolar disorder, also lacked an updated PASARR. The DON confirmed the oversight and acknowledged the absence of a facility policy on PASARR updates.
A facility failed to request a PASARR Level I and Level II evaluation for a resident admitted with Alzheimer's, anxiety, and psychotic disorders. The DON could not locate the PASARR in the medical record and confirmed it was missing. The DON and Administrator determined it was likely lost or misplaced, and the DON acknowledged responsibility for updating PASARRs, noting the facility lacked a policy on them.
The facility failed to obtain physician orders before administering oxygen therapy and did not maintain oxygen flow rates as ordered for two residents. One resident with COPD received oxygen at a higher flow rate than prescribed, while another received continuous oxygen without an active order. The nursing staff did not verify and adjust oxygen flow rates according to physician orders, leading to incorrect administration of oxygen levels.
A resident with multiple pressure ulcers did not receive proper infection control during wound care. The RN failed to change gloves and perform hand hygiene between treating different wound sites, contaminating the medication container. The facility's policy requires hand hygiene before and after resident contact, which was not followed.
A resident with COPD was found with an Albuterol inhaler at her bedside, which she stated was necessary for managing severe attacks. However, there was no physician order authorizing her to self-administer the medication, nor was there an order for the inhaler itself. The DON confirmed that residents should not have medications at the bedside without an assessment and physician order. The facility's policy required an interdisciplinary team assessment and care plan update for self-administration, which had not been completed for this resident.
A resident in an LTC facility, who was cognitively intact and preferred morning showers, reported receiving only two showers in three weeks, contrary to her preferences and the facility's schedule. The DON confirmed the resident's needs were not met, with documentation showing a lack of showers over the last two weeks, highlighting a failure to provide person-centered care.
A resident with stomach cancer requiring J-tube feeding did not receive necessary nutrition for several days due to communication lapses and procedural oversights. The facility failed to have tube feeding equipment ready upon admission, and there was a delay in transcribing the dietitian's recommendations into the medical record, resulting in unmet nutritional needs.
A resident with epilepsy was prescribed 800 mg of Carbamazepine daily but received only 400 mg due to a transcription error in the facility's records. The resident, feeling unwell, discharged themselves after the facility failed to provide accurate pharmaceutical services, as confirmed by the DON.
Failure to Timely Refund Deceased Resident’s Funds to Representative
Penalty
Summary
The facility failed to refund all monies due to a deceased resident’s representative within 30 days of the resident’s death, as required by regulation and the facility’s own refund policy. The resident had resided in the facility for approximately nine years and was Medicaid-eligible, with a gross monthly income of $1,159.22 and a personal needs allowance of $160.00 per month. Billing records showed that the resident’s husband paid a monthly patient responsibility of $314.92 from their joint checking account. Despite the resident’s death, this patient responsibility continued to be drawn from the joint account in the month following death, 13 days after the resident had passed away. Email correspondence showed that the Business Office Manager notified the corporate office accounting department of the resident’s death and requested removal of the resident from Automated Clearing House (ACH) payments. Additional emails documented that the facility was aware the husband was requesting a refund and that the family was due a larger refund than initially believed. At the time of the survey, over four months after the resident’s death, the Corporate Regional Director of Operations and the Administrator confirmed that the resident’s husband was still owed a refund totaling $1,905.35 and that no refund had been issued. The Administrator stated that the Business Office Manager did not have authority to issue refund checks and that they had been waiting for the corporate office to process the refund, contrary to the facility’s written policy requiring final accounting and conveyance of funds within 30 days of death.
Failure to Provide Necessary Care and Timely Assessment Resulting in Resident Neglect and Death
Penalty
Summary
A facility failed to protect a resident's right to be free from neglect by not providing necessary care and services to a totally dependent resident, resulting in the resident being found unresponsive and exhibiting physical signs consistent with having been deceased for several hours prior to discovery. The resident, an elderly female with severe cognitive impairment, was totally dependent on staff for all activities of daily living, including mobility, nutrition via gastrostomy tube, and required frequent monitoring and repositioning. Despite physician orders for regular care and assessments, documentation and interviews revealed that staff did not provide the required care or timely assessments during the shift preceding the resident's death. On the evening and overnight shifts, multiple staff members failed to adequately monitor or assess the resident. The assigned LPN reported seeing the resident sleeping at various times but did not check for responsiveness or breathing, and documentation was inconsistent with the resident's actual condition and care needs. The CNA assigned to the resident did not provide required care, such as repositioning, and incorrectly documented that the resident was unavailable for care, later admitting to confusing her with another resident. Another CNA arriving for the overnight shift found the resident cold and stiff to the touch but did not report these findings to a nurse. Interviews revealed that staff felt pressured by facility leadership to provide false witness statements regarding the incident. When the resident was eventually found unresponsive, staff initiated CPR and called emergency services, but EMS and hospital records indicated the resident had been deceased for several hours, as evidenced by rigor mortis and a significantly lowered core body temperature. The facility's failure to provide care, timely assess, and recognize a change in the resident's condition, as well as the failure to initiate life-saving interventions in a timely manner, resulted in Immediate Jeopardy. The facility's own policies defined neglect as failure to provide necessary goods and services to avoid harm, and staff interviews and documentation confirmed that required care was not provided.
Failure to Investigate Alleged Neglect and Provide Timely Care
Penalty
Summary
The facility failed to investigate an allegation of neglect and did not ensure staff recognized a change in a resident's condition or provided timely interventions. A resident with severe cognitive impairment, multiple comorbidities including encephalopathy, diabetes, stroke, heart failure, and dementia, and who was dependent on staff for all activities of daily living, was found unresponsive after midnight. Staff initiated CPR and the resident was transferred to the hospital, where EMS and hospital records documented the resident was already in rigor mortis with a core body temperature of 90.7°F, indicating the resident had been deceased for some time before staff intervention. The care plan required repositioning every two hours due to a stage 4 pressure wound, but documentation and staff interviews revealed inconsistencies regarding whether care was provided during the evening shift. Staff interviews and medical record reviews showed that the assigned CNA for the 3 PM to 11 PM shift did not provide care to the resident and documented the resident as not available, despite being assigned to her. Multiple staff accounts conflicted regarding the timing and actions taken during the code blue event, with some staff stating the resident was already deceased and in rigor mortis when found. The facility administration did not conduct a thorough investigation, failing to obtain statements from all involved staff, including the staff member who initially alleged neglect, and did not seek statements from EMS responders. The facility also delayed reporting the incident to the State Agency, submitting the required Immediate and Five Day reports approximately 27 days after becoming aware of the allegation. The Administrator and DON were unable to explain the discrepancies in staff accounts or provide evidence that the resident received timely and appropriate care. They also could not account for the delay in reporting the incident or the lack of a comprehensive investigation, including not interviewing key witnesses or considering the hospital's findings of rigor mortis. There was no evidence that the facility addressed potential neglectful actions prior to or during the code blue event.
Failure to Provide Timely Assessment and Care Resulting in Resident Death
Penalty
Summary
A deficiency occurred when facility staff failed to provide care and services in accordance with a resident's care plan, preferences, and professional standards of practice. The resident, who had severe cognitive impairment, was totally dependent on staff for all activities of daily living, and required continuous tube feeding, routine hydration, and frequent monitoring, was not properly assessed or cared for during a specific shift. Staff did not perform required ADL care, repositioning, or timely assessments, and failed to recognize or respond to a change in the resident's condition. Documentation was inconsistent, with some staff noting the resident was 'not available' for care, while others admitted to not providing care or confusing the resident with another individual. During the shift in question, the assigned nurse administered medications via g-tube but did not physically assess the resident for responsiveness or breathing. The CNA assigned to the resident did not provide any ADL care, did not reposition the resident, and incorrectly documented the resident as unavailable. Another CNA, upon starting her shift, found the resident cold and stiff to the touch but did not report this to nursing staff. When the resident was eventually found unresponsive, staff initiated CPR and called EMS, but EMS and hospital records indicated the resident had been deceased for several hours prior to discovery, exhibiting rigor mortis and a significantly lowered body temperature. Interviews with staff revealed a lack of timely and appropriate assessment, failure to follow care plan interventions, and inaccurate or delayed documentation of care and vital signs. There was also a lack of clear communication and role assignment during the emergency response. The facility's policies required accurate documentation and care based on comprehensive assessment, but these were not followed. The failure to provide timely care, recognize a change in condition, and initiate life-saving interventions resulted in Immediate Jeopardy for the resident.
Failure to Conduct QAPI Review After Resident Death and Alleged Neglect
Penalty
Summary
The facility failed to conduct a Quality Assurance and Performance Improvement (QAPI) meeting after allegations of neglect and concerns were identified regarding the death of a resident. The resident was found unresponsive just after midnight, and staff initiated CPR before transferring the resident to the hospital. Hospital and EMS records indicated the resident exhibited signs of rigor mortis and a low core body temperature, suggesting the resident had been deceased for some time prior to being found. There were inconsistencies in staff witness statements, documentation, and timelines regarding when the resident was last cared for and when CPR was initiated. The Nursing Home Administrator (NHA) acknowledged responsibility for monthly QAPI meetings and stated that incidents such as neglect and abuse were typically brought to these meetings. However, the NHA did not bring this incident to QAPI, citing no concerns with staff performance during the code blue event. The Medical Director and DON were aware of the circumstances and documentation discrepancies, including a CNA's false documentation that the resident was not in the facility during the relevant shift. Despite being aware of an allegation of neglect, the facility did not address the incident through the QAPI process.
Failure to Ensure Ethical Practices and Accurate Reporting in Resident Death
Penalty
Summary
The facility failed to ensure staff adhered to ethical practices and professional standards, resulting in inconsistent and misleading statements regarding the circumstances of a resident's death. Staff provided conflicting accounts about the last time the resident was observed, the care provided, and the initiation of CPR. Documentation in the resident's medical record did not align with staff witness statements, and there were discrepancies in the reported times and actions taken during the code event. For example, one LPN documented that the resident was alert and oriented at a time when she later stated she had not assessed the resident, and a CNA's documentation conflicted with her statements about providing care. Further, high-level personnel oversight was lacking, as evidenced by the failure of the DON and Administrator to ensure accurate and truthful reporting. Staff reported being instructed to provide false witness statements under threat of job loss, and there was evidence that the crash cart was placed in the resident's room prior to EMS arrival to give the impression that CPR was in progress. The DON and Administrator denied knowledge of the resident being deceased prior to CPR and failed to report allegations of neglect and ethical violations when they were brought to their attention by staff. The facility also failed to develop effective lines of communication to encourage immediate reporting of violations without fear of retaliation. When a staff member reported allegations of neglect and unethical behavior, these concerns were not reported to the appropriate authorities. The compliance officer confirmed that ethical behavior was expected, but the facility's actions did not support an environment where staff could report violations without fear. These failures contributed to an inadequate investigation into the resident's death and undermined the facility's compliance and ethics program.
Failure to Implement Timely and Appropriate Fall Prevention for High-Risk Resident
Penalty
Summary
A resident with a history of falls, cognitive impairment, and multiple high-risk medications was admitted to the facility and experienced several unwitnessed falls, one of which resulted in a head injury requiring emergency care. Despite documented risk factors such as previous falls, use of opioids, anti-anxiety, and antidepressant medications, and significant physical and cognitive deficits, the facility failed to timely identify and implement appropriate fall prevention interventions. The resident's care plan did not include a fall prevention focus for over six weeks after admission, and interventions were not consistently updated or individualized following each fall. The facility's assessments and documentation were inconsistent and incomplete. Fall risk evaluations repeatedly scored the resident as moderate/low risk, even after multiple falls, and did not reflect the resident's actual fall history or changes in condition. There was a lack of timely and accurate care planning, with missing or backdated assessments and omitted interventions related to the resident's medication regimen and fall risk. Staff interviews revealed that supervision practices were inadequate, with residents, including the affected individual, left unsupervised in wheelchairs near the nurses station, especially during busy periods such as medication pass and shift changes. Family members and staff expressed concerns about the lack of supervision and the resident's inability to use the call light due to cognitive impairment. The care plan interventions, such as encouraging call light use, were not appropriate for the resident's condition. The facility did not have a formal falls prevention program, and communication among staff regarding fall risks and interventions was informal and insufficient. These failures resulted in actual harm to the resident, who suffered a fall with injury.
Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement appropriate interventions to provide adequate supervision and prevent falls with injury for a resident with a known history of repeated falls and high-risk medication use. The resident, an elderly female with generalized muscle weakness, impaired mobility, moderate cognitive impairment, and a history of falls, was admitted from an acute care hospital. Despite multiple risk factors, including cognitive deficits, incontinence, and use of high-risk medications such as antidepressants, opioids, and antiplatelets, the facility did not timely initiate or update a comprehensive fall prevention care plan. For over six weeks after admission, there was no fall prevention focus in the care plan, and interventions were limited to keeping the call light within reach, which was not appropriate given the resident's cognitive impairment. Observations and interviews revealed that the resident experienced multiple falls during her stay, including an unwitnessed fall from a wheelchair near the nurses' station that resulted in a head laceration requiring emergency care. Staff interviews indicated that while it was common practice to place high fall risk residents near the nurses' station, supervision was inconsistent, especially during busy periods such as medication pass and after dinner. Staff also reported that care plan interventions and safety directives were not always clearly communicated or documented in the electronic record, leading to reliance on verbal reports and inconsistent implementation of fall precautions. Record review and staff statements confirmed that the facility's fall prevention program and protocols were not followed as required. The resident's care plan was not updated in a timely manner to reflect her fall risk, and interventions were not adequately tailored to her needs, particularly given her cognitive impairment and inability to reliably use the call light. The facility's own guidelines required standardized risk assessments, increased supervision, and prompt care plan updates, but these measures were not effectively implemented, resulting in actual harm to the resident.
Failure to Maintain Effective QAPI Program and Monitoring Documentation
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) program by not identifying and addressing repeated deficiencies and by not ensuring complete monitoring documentation for corrective action plans. Previous surveys had resulted in enforcement actions for deficiencies related to abuse and neglect, failure to investigate and correct alleged violations, and accident hazards. Despite these repeated issues, the QAPI committee did not systematically monitor or document the progress of corrective actions, and there was a lack of sustained oversight, particularly due to frequent changes in the Director of Nursing (DON) position. The Nursing Home Administrator (NHA) was unable to provide documentation of completed Performance Improvement Plans (PIPs) or explain how substantial compliance was determined for previous citations. The facility's own guidelines required ongoing, systematic monitoring of performance indicators and data collection for at least one year, but these processes were not followed. The NHA acknowledged that the DON was responsible for ensuring nursing-related corrective actions were active and sustained, but admitted there was a failure to track and implement these measures. As a result, the facility did not have an effective system in place to ensure that identified problems were corrected and prevented from recurring, and monitoring documentation was incomplete or missing.
Failure to Ensure Compliance and Ethics Program Adherence by DON
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) adhered to ethical expectations and professional standards, as evidenced by backdating evaluations with incorrect documentation. There was no evidence that the DON had received education or competency training for the role, nor was there documentation of the DON's signed job description or acknowledgement of Compliance and Ethics Program orientation education. The Human Resource Assistant, who also served as the Compliance Officer, stated that compliance program information was provided during employee orientation, but did not participate in clinical or resident care meetings and only became involved in employee-related situations such as investigations or terminations. Additionally, compliance program posters, which should have been readily visible for employees, were only present on the Assisted Living Facility side of the building and not on the Skilled Nursing side. The Nursing Home Administrator confirmed that the required compliance documentation for the former DON was missing from the employee file. The facility's own standards outlined the need for sufficient resources, ongoing communication, and annual training to promote quality care, but these requirements were not met as described in the findings.
Failure to Maintain Accurate and Complete Medical Records and Fall Risk Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, resulting in incorrect documentation and backdating of records by the former Director of Nursing (DON). The DON backdated Fall Risk Evaluations and did not update risk scores after the resident experienced multiple unwitnessed falls. These assessments were not completed in a timely manner and did not reflect changes in the resident's condition, such as prior fall history and subsequent falls, which should have increased the fall risk score to a high-risk category. The DON also failed to ensure that individualized care plan interventions were documented, and the Fall Risk Evaluations remained at a moderate/low risk score despite evidence to the contrary. The Minimum Data Set (MDS) Coordinator inaccurately recorded the resident's fall history in the MDS assessments, failing to thoroughly check all medical records. This led to incorrect coding of fall history and the absence of a timely fall prevention care plan. The resident, a 58-year-old female with moderate cognitive impairment, generalized muscle weakness, difficulty walking, and a history of falls, did not have a fall prevention care plan focus developed for over six weeks after admission. The MDS Coordinator acknowledged these errors during interviews and confirmed that the previous coordinator missed critical information regarding fall history and high-risk medication use. The medical record review showed inconsistencies between the resident's actual condition and the documentation in the clinical record. Despite the resident's history of falls and use of high-risk medications, the care plan did not address fall prevention in a timely manner, and the risk assessments were not updated to reflect changes in the resident's status. The DON and nurses' job descriptions required accurate and timely documentation, which was not met in this case, compromising the integrity of the resident's medical information.
Neglect in Fall Prevention and Monitoring
Penalty
Summary
The facility failed to provide necessary care and services to prevent falls and ensure appropriate post-fall monitoring for a resident with cognitive and physical impairments. This resident, who was on blood thinner medication and had a history of repeated falls, experienced two unwitnessed falls within a ten-day period. On both occasions, the resident was left unattended in the activity room by CNAs who were supposed to supervise her as part of the fall prevention program. The first fall occurred when a CNA left the room to give another resident a shower, and the second fall happened when a CNA left the resident alone to respond to a call light. After the second fall, the assigned nurse failed to initiate neurological checks or notify the physician until nearly 12 hours later, despite the resident developing a bruise and a hematoma on her forehead. The resident, who was at high risk for intracranial hemorrhage due to her anticoagulant therapy, was not appropriately monitored, and the developing hematoma went unnoticed until the following day. The facility's Director of Nursing confirmed that the resident's physician was not informed of the fall in a timely manner, and the resident remained in the facility without adequate monitoring. The facility's failure to maintain effective processes for educating staff and offering adequate supervision placed all residents at risk for injury. The education on expectations for the fall prevention program was insufficient, as only a small portion of the nursing staff received the in-service, and no activities staff were included. This lack of comprehensive training and supervision contributed to the neglect of the resident's needs and the subsequent harm she experienced.
Inadequate Supervision Leads to Resident Falls and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls and fall-related injuries for a resident with cognitive and physical impairments. The resident, who was on blood thinner medication and had a history of repeated falls, was left unattended in the activity room on two separate occasions, resulting in falls from her wheelchair. The first incident occurred when a CNA left the resident to attend to another resident, and the second incident happened when the resident was left alone while the RN was attending to another emergency. The resident's medical history included atrial fibrillation, stroke, lack of coordination, repeated falls, generalized muscle weakness, unsteadiness on her feet, right knee contracture, anxiety disorder, paranoid schizophrenia, and Alzheimer's disease. Her cognitive impairment was severe, as indicated by a low score on the Brief Interview for Mental Status. Despite being identified as a high fall risk, the resident's care plan was not adequately updated to reflect her need for increased supervision, and interventions such as a non-slip pad for her wheelchair were deemed insufficient. The facility's failure to monitor the resident closely resulted in actual harm, as the resident suffered a bruise and a hematoma on her forehead after the second fall, requiring hospital transfer for diagnostic testing. The facility's protocols for fall prevention were not effectively implemented, as evidenced by the lack of supervision and the absence of timely neurological checks and physician notification following the falls.
Inadequate Staffing Levels Impact Resident Care and Safety
Penalty
Summary
The facility failed to maintain sufficient staffing levels to provide adequate supervision and meet the care needs of residents, as observed during a survey. The facility had 39 licensed beds with an average daily census of 32 residents, many of whom required significant assistance with activities of daily living. Despite this, the facility was often staffed with only three CNAs on the day and evening shifts, and two to three on the night shift, which was insufficient given the high acuity of care required by the residents. Observations revealed that CNAs were rushed, call light response times were delayed, and staff were unable to provide the necessary care and supervision, particularly for residents at high risk for falls. Interviews with staff, including CNAs and nurses, highlighted the challenges faced due to inadequate staffing. CNAs were required to rotate through the activity room to supervise residents at risk for falls, leaving only two CNAs on the floor to manage other residents' needs. This rotation system significantly impacted their ability to provide timely care, complete tasks such as showers, and respond to call lights. Staff expressed concerns about being overwhelmed and unable to meet the care needs of their assigned residents, with some residents having to wait for assistance or not receiving the necessary care. The facility's administration, including the Administrator and DON, were reportedly unaware of the extent of the staffing issues and the impact on resident care. The staffing coordinator confirmed that staffing decisions were based on census numbers rather than the actual care needs of residents, and acknowledged that the workload would be more manageable with additional CNAs. Despite staff complaints and the evident strain on care delivery, the facility continued to operate with insufficient staffing levels, particularly during the evening shift when resident behaviors associated with dementia increased.
Failure to Notify Physician of Resident Fall
Penalty
Summary
The facility failed to promptly notify the physician of an unwitnessed fall involving a resident at high risk for bleeding. The resident, a female with severe cognitive impairment and multiple diagnoses including atrial fibrillation and Alzheimer's disease, was on anticoagulant medication, increasing her risk for bleeding. On the night of the incident, the resident fell in the activity room, and although the attending physician was notified, the time of notification was not documented. The physician assessed the resident almost 12 hours later, discovering a hematoma on her forehead, and ordered her to be sent to the hospital for evaluation. The incident occurred when the resident was left unattended in a common area despite being agitated, leading to her fall from a wheelchair. The assigned nurse, RN M, heard the resident moaning and found her on the floor. Although RN M assessed the resident and found no immediate injuries, she only attempted to notify the Advanced Practice Registered Nurse (APRN) once and did not receive a callback. The nurse did not make further attempts to contact the physician or APRN, nor did she escalate the situation to the Director of Nursing (DON) as per facility policy. The following morning, the attending physician discovered the resident's hematoma during routine rounds. The facility's policy required nurses to notify the physician immediately after a fall, especially for residents on blood thinners due to the risk of brain bleeding. The DON confirmed that the nurse did not follow the protocol of making multiple attempts to contact a provider or escalating the issue if no response was received. The job descriptions for both RN and LPN staff emphasized the importance of timely and accurate reporting of incidents and changes in resident conditions.
Failure to Investigate and Supervise Leads to Repeated Falls
Penalty
Summary
The facility failed to implement its abuse and neglect prohibition policy and procedures, specifically in conducting a thorough investigation of a fall with injury to rule out neglect and determine if reporting was necessary. A resident, who was at high risk for falls due to conditions such as atrial fibrillation, stroke, and Alzheimer's disease, experienced two unwitnessed falls in the activity room. The first fall occurred when the resident was left unattended by a CNA who left to attend to another resident, and the second fall happened under similar circumstances when the resident was again left unattended. The facility's policies required timely and thorough investigations of all incidents, but the investigation into the resident's falls was inadequate. The DON acknowledged that the CNAs did not follow instructions to ensure the resident's safety, and the resident was not monitored closely for bleeding after the fall. Despite these findings, the DON did not consider the incidents as neglect, and the facility did not report them as such. The Administrator, responsible for implementing the abuse and neglect policy, relied heavily on the DON's findings and did not identify the possibility of an inappropriate or ineffective plan of care. The facility's failure to conduct a thorough investigation and ensure adequate supervision for the resident led to repeated falls and potential neglect. The care plans did not reflect the resident's need for increased supervision, and the facility did not identify or address the root cause of the falls. The Administrator later acknowledged the lack of detail in the investigation and the need for more rigorous questioning to ensure incidents met reporting criteria.
Inadequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) care for three residents, specifically in the areas of fingernail care, oral care, and dressing. Resident #2, a female with severe cognitive impairment, was observed with long, uneven, and dirty fingernails, despite being dependent on staff for personal hygiene. There was no documentation of care refusals, and staff confirmed that nail care should be performed at least twice weekly. Similarly, Resident #5, who was cognitively intact but required substantial assistance, reported her fingernails had not been cut or filed since admission, and staff confirmed that only licensed nurses were allowed to cut nails. Resident #1, who had severe cognitive impairment and required assistance with ADLs, was observed with poor oral hygiene and soiled clothing. Her teeth had plaque, and food particles were visible in her mouth, indicating a lack of regular oral care. The CNA responsible for her care admitted to brushing her teeth only two days prior and acknowledged that her clothing was soiled from a food spill. The Director of Nursing confirmed that CNAs were responsible for personal hygiene tasks and that licensed nurses should supervise and ensure necessary care is provided. The facility's policy stated that residents unable to perform ADLs independently should receive necessary services to maintain good grooming and hygiene. However, the observations and interviews revealed a failure to adhere to these policies, resulting in inadequate care for the residents involved. The lack of documentation and oversight contributed to the deficiencies in providing essential ADL care, as evidenced by the conditions of the residents' fingernails, oral hygiene, and overall appearance.
Failure to Provide Private Communication Access
Penalty
Summary
The facility failed to provide reasonable access to communication methods, specifically telephones and internet, for three residents. Resident #1's phone and internet stopped working, preventing him from maintaining his usual daily contact with his daughter. Despite a meeting with the Ombudsman and the facility's Administrator, the issue remained unresolved, forcing the family to purchase a tablet for communication, which was less effective. Resident #1's MDS assessment indicated no cognitive impairment and highlighted the importance of private phone use. Resident #2 experienced similar issues, with her room phone being non-functional for weeks, requiring her to use the front desk phone without privacy. Her MDS assessment showed moderate cognitive impairment and emphasized the importance of private phone use. Resident #3, who did not have a cell phone, relied on his room phone, which was also out of order. His son, unable to reach him for a month, expressed frustration over the lack of communication, especially during the holiday season. Resident #3's MDS assessment indicated no cognitive impairment and a preference for private phone use. The facility's staff, including CNAs and RNs, confirmed the residents' inability to use their room phones and the lack of communication from management regarding the issue. The Administrator acknowledged the problem stemmed from a service disconnection due to an unpaid balance after a management change. Despite the availability of phones at the nurses' station and activity room, privacy was not ensured, and no formal notification was given to residents or families about the situation. The facility's policy required phones to be available for private use, accommodating residents' needs, which was not met.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and sanitation of food items in both the main kitchen pantry and the resident pantry. During a tour of the kitchen pantry, it was observed that several dry food packages were opened without any indication of the opened date, expiration date, or discard date. These included an open soy sauce bottle, a bag of crispy onions, tortilla chips, a bag of dry mashed potato mix, and expired tortilla wraps. Additionally, taco shells were found without original packaging, making it impossible to determine their expiration date. The Food and Nutrition Manager, who had recently started working at the facility, acknowledged the responsibility of the kitchen staff to date food items to prevent pests and food-borne illnesses. In the resident pantry, unsanitary conditions were noted, including dirty containers of dry cereal with a sticky brown substance on the lids and an open bag of cereal without a date. The refrigerator contained various food items, some of which were improperly stored, such as a jug of lemonade with a brown stain on the lid and a nutritional supplement bottle that had spilled. The refrigerator was also found to be dirty, with a sticky brown substance on the stainless-steel container and caked-on brown substance in the drawers. Kitchen Aide H admitted that the refrigerator needed cleaning and stated it was cleaned once a week, but acknowledged it might have gotten dirty during the night shift. The Food and Nutrition Manager confirmed the expectation for staff to maintain cleanliness and proper labeling of food items.
Failure to Update PASARR for New Mental Disorder Diagnoses
Penalty
Summary
The facility failed to request updated Preadmission Screening and Resident Review (PASARR) Level I Screens for two residents who received new mental disorder diagnoses. Resident #24 was admitted with acute kidney failure and type II diabetes and later diagnosed with dementia and major depressive disorder. Despite these new diagnoses, an updated Level I PASARR screen was not completed. The resident was non-verbal, required substantial assistance for all activities of daily living, and exhibited behaviors such as restlessness and agitation. The Director of Nursing (DON) confirmed that she was unaware of the requirement to submit a new Level I PASARR for the resident. Similarly, Resident #14, who was admitted with chronic pain, major depressive disorder, generalized anxiety disorder, and heart failure, received a new diagnosis of bipolar disorder. However, this new diagnosis was not included in the Level I PASARR. The resident was treated with Abilify for bipolar disorder, and her care plan included psychiatric evaluations and monitoring for mood and behavior changes. The DON acknowledged the oversight and confirmed that the facility did not have a policy on updating PASARRs.
Failure to Complete PASARR Evaluation for Resident
Penalty
Summary
The facility failed to request a Preadmission Screening and Resident Review (PASARR) Level I and Level II evaluation for a resident reviewed for PASARR. The resident was admitted from the hospital with diagnoses including vascular dementia, Alzheimer's disease, major depressive disorder, and generalized anxiety disorder. The Admission Minimum Data Set (MDS) indicated the resident had severely impaired cognitive skills and was receiving antipsychotic and antidepressant medications. Upon review, the Director of Nursing (DON) could not locate the resident's Level I PASARR in the medical record and confirmed it was not present in the social services tab or elsewhere in the chart. The DON and the Administrator determined that the Level I PASARR was likely lost or misplaced, but they could not confirm if it was ever completed. The DON acknowledged responsibility for updating PASARR and stated that the facility did not have a policy on PASARRs.
Failure to Obtain Physician Orders and Maintain Oxygen Flow Rates
Penalty
Summary
The facility failed to obtain physician orders before administering oxygen therapy and did not maintain oxygen flow rates as ordered by the physician for two residents. Resident #12, who was readmitted with chronic obstructive pulmonary disease (COPD) and required continuous oxygen, was observed receiving oxygen at a higher flow rate than prescribed. The physician's order was for 1 liter per minute, but observations showed the oxygen concentrator set at 4 liters per minute and later at 3 liters per minute. The nursing staff, including LPN B, failed to verify and adjust the oxygen flow rate according to the physician's order, despite being aware of the correct prescription. Resident #29, admitted with chronic kidney disease and other conditions, was observed receiving continuous oxygen therapy without an active physician order. The medical record review revealed no orders for oxygen therapy, and the attending physician confirmed that the resident did not require continuous oxygen and could manage on room air. The staff, including RN G, was unable to find an order for oxygen therapy in the electronic medical record until a verbal order was signed on a later date, indicating a lack of proper documentation and verification of physician orders before administering oxygen. The facility's policy intended to ensure residents received necessary respiratory care in accordance with professional standards and the resident's care plan was not followed. The Director of Nursing acknowledged the failure of the nursing staff to verify and adjust oxygen flow rates as per physician orders, which led to the administration of incorrect oxygen levels to the residents. This deficiency highlights a lapse in adherence to established protocols for respiratory care management within the facility.
Inadequate Infection Control During Wound Care
Penalty
Summary
Facility staff failed to adhere to proper infection prevention and control practices during wound care for a resident with multiple pressure ulcers. The resident, who was admitted with a diagnosis of an unstageable pressure ulcer in the sacral region and other health conditions including MRSA, was receiving hospice care. During an observed wound care session, the Registered Nurse (RN) did not change gloves or perform hand hygiene between treating different wound sites, which is inconsistent with professional standards of practice and the facility's hand hygiene policy. The RN was observed applying barrier cream to the resident's sacral wound and right upper arm without changing gloves or washing hands after removing the old dressing and cleansing the wound. This action contaminated the medication container and potentially spread infection. The RN acknowledged the mistake after the procedure, and the Director of Nursing confirmed that gloves should have been changed between each step of the wound care process. The facility's policy requires hand hygiene before and after resident contact and after contact with contaminated surfaces, which was not followed in this instance.
Failure to Promote Self-Administration of Medication
Penalty
Summary
The facility failed to promote the right to self-administer medication for a resident with chronic obstructive pulmonary disease (COPD). The resident, who was cognitively intact and had no behavioral symptoms, had a hand-held Albuterol inhaler on her tray table, which she stated was necessary for managing severe COPD attacks. Despite the resident's assertion that her doctor wanted her to have the inhaler, there was no physician order authorizing her to self-administer the medication, nor was there an order for the inhaler itself. The Director of Nursing (DON) confirmed that residents should not have medications at the bedside unless assessed and deemed capable of self-administration. The inhaler was removed from the resident's room by the DON, who informed the resident that a nursing assessment and physician order were required for her to keep the inhaler. The facility's policy indicated that residents could self-administer medication if deemed clinically appropriate by the interdisciplinary team, with a physician order and care plan update required, but these steps had not been completed for the resident.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's right to choose the type and frequency of baths, as required by their preferences. A resident, who was cognitively intact and had expressed a preference for morning showers, reported receiving only two showers in three weeks since admission, despite being scheduled for showers twice a week. The resident expressed dissatisfaction with the lack of showers, feeling unclean and noting the absence of disposable wipes for personal hygiene. The Director of Nursing (DON) confirmed that the resident should have been offered showers according to her preferences and acknowledged the failure to meet the resident's needs. Documentation showed the resident received showers only on two specific dates, with no record of showers in the last fourteen days. The DON verified that the resident's experience was unacceptable and emphasized the importance of honoring residents' choices and preferences as part of person-centered care.
Failure to Implement Timely Tube Feeding for Resident
Penalty
Summary
The facility failed to implement necessary interventions to ensure the optimal nutritional status for a resident who required assisted nutrition and hydration via a jejunostomy tube (J-tube). The resident, with a medical history of stomach cancer, was admitted to the facility with specific nutritional needs that included tube feeding. However, upon admission, there was a lack of clear instructions regarding the type or rate of tube feeding formula, and the facility did not have the necessary equipment ready for the resident's arrival. The Director of Nursing (DON) attempted to verify the resident's diet and tube feeding orders with the hospital but was unsuccessful. Consequently, the resident did not receive tube feedings for three to four days after admission, relying instead on thickened liquids and pureed food, which he could not consume adequately. The Registered Dietitian (RD) assessed the resident and recommended a specific tube feeding formula and rate, but the order was not added to the electronic medical record until several days later, delaying the initiation of the tube feeding. The delay in providing the necessary tube feeding was compounded by communication lapses and procedural oversights. The DON contacted the RD late in the day after the resident's admission, and the RD's recommendations were not promptly transcribed into the medical record. Additionally, the facility's policy required the admitting nurse to obtain physician orders for tube feeding and notify the dietitian, but these steps were not effectively executed, resulting in the resident's nutritional needs not being met in a timely manner.
Medication Dosage Error for Resident with Epilepsy
Penalty
Summary
The facility failed to provide accurate pharmaceutical services for a resident who was admitted with a history of epilepsy and a recent fall due to not taking seizure medication on time. Upon discharge from the hospital, the resident was prescribed Carbamazepine 200 mg, to be taken as two tablets in the morning and two at bedtime, totaling 800 mg daily. However, the facility's medical record inaccurately transcribed this order, resulting in the resident receiving only 400 mg daily during their stay. This discrepancy was confirmed by the Director of Nursing (DON) after the resident expressed dissatisfaction with the care and noted feeling unwell due to the incorrect dosage. The facility's interdisciplinary team, responsible for reviewing newly admitted residents' charts, failed to identify the incorrect dosage during their daily clinical meetings. The facility's policy on pharmacy services, which includes procedures to ensure accurate medication administration, was not adhered to, leading to the resident receiving an incorrect dose of Carbamazepine. The DON acknowledged the error and confirmed that the transcription mistake was not caught during the review process, resulting in the resident's decision to discharge themselves due to dissatisfaction with the care received.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
