Aspire At Evans
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Myers, Florida.
- Location
- 3735 Evans Ave, Fort Myers, Florida 33901
- CMS Provider Number
- 106000
- Inspections on file
- 32
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Aspire At Evans during CMS and state inspections, most recent first.
The facility failed to complete individualized baseline care plans within 48 hours of admission for three newly admitted residents. One resident admitted for rehab after a fall had a baseline care plan that was essentially blank, lacking goals, instructions, and any interventions, including those related to a known fall history. Another resident admitted from the hospital with chest pain had an incomplete baseline care plan in which a falls/safety goal was marked but no interventions were documented. A third resident admitted with acute respiratory failure with hypoxia had a baseline care plan with multiple goals (falls/safety, oral/dental, pain, anticoagulant use) circled but no interventions identified. The unit manager and DON confirmed that these baseline care plans were not completed as required by facility policy.
A resident admitted after a fall at home with a closed head injury and transferred for rehabilitation had physician orders for OT, PT, and speech therapy evaluations and treatment that were not completed as directed. Although a wheelchair evaluation and provision occurred shortly after admission, the therapy department did not perform the ordered OT, PT, and speech evaluations within its usual 48-hour timeframe and instead scheduled them for a later date. The evaluations were never carried out because the resident was sent to the hospital for a change in mental status, and both the therapy director and DON confirmed that the physician-ordered therapy evaluations were not completed.
The facility did not maintain an effective pest control program, as evidenced by ongoing reports and direct observations of roaches, ants, and other pests in resident rooms and common areas. Staff and residents described frequent pest sightings, and pest control logs documented repeated infestations despite regular treatments. The persistent presence of pests affected at least two residents and was acknowledged by multiple staff members, indicating a failure to ensure a pest-free environment.
The facility did not consistently assign or document a licensed nurse as charge nurse on evening and night shifts, leading to confusion among nursing staff about supervisory roles and oversight. Staff interviews revealed uncertainty about who was responsible for patient care leadership during these times, and assignment sheets lacked clear identification of a charge nurse.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with severe cognitive impairment and dementia was physically restrained by two CNAs, who held the resident by the head, chest, arms, and feet in an attempt to keep her seated while she was agitated and attempting to get up. This resulted in bruising to the resident's chest and limbs. The incident was observed by an RN, who intervened and reported the event, and facility leadership acknowledged that such restraint was not permitted and constituted abuse.
The facility did not complete required documentation or provide written notification regarding transfer, discharge, appeal rights, or bed-hold policies for three residents who were transferred or discharged. In each case, there was a lack of progress notes, discharge notices, and bed-hold documentation, and staff were unable to provide the necessary records or explain the absence of these documents.
Two residents were not permitted to return to the facility after hospitalization, with missing documentation and unclear decision-making regarding their readmission. Required notifications, such as bed hold and discharge notices, were not provided, and facility staff could not clearly explain or document the reasons for denying return, despite policy and regulatory requirements.
Two dependent residents did not receive scheduled assistance with ADLs, including nail care and showers, as required by facility policy. Both were observed with dirty, untrimmed nails and unkempt hair, and staff interviews confirmed that care was not provided as scheduled, with no refusals documented. The DON and administrator acknowledged that nail care and showers should have been performed according to established routines.
Two residents experienced significant weight loss due to inconsistent meal intake documentation, hindering the evaluation of nutritional interventions. One resident, with a history of dehydration and altered mental status, lost 13% of her weight in two weeks despite interventions. Another resident, with alcohol dependence, faced similar issues, with meal refusals and weight loss not consistently documented. The DON confirmed the lack of documentation and communication, impacting the residents' nutritional care.
The facility failed to prevent avoidable falls and provide adequate supervision for three residents, resulting in serious injuries. A resident with severe cognitive impairment fell and fractured her nose, with the facility failing to consider her claim of being pushed. Another resident with dementia sustained a wrist fracture due to inadequate supervision, and a third resident experienced multiple falls, including a subarachnoid hemorrhage, without specific fall prevention interventions in place.
The facility failed to maintain safe and sanitary food storage and preparation conditions. Unlabeled food items were found in the refrigerator, and staff were not trained to test the sanitizing agent in the dishwasher. Dusty and debris-covered plastic covers were used for clean plates, and dirty ceiling tiles and vents were observed over food preparation areas. The Maintenance Director admitted to not cleaning the vents and tiles monthly as required.
The facility failed to provide a structured activity program for residents in the memory care unit, resulting in a lack of engagement and stimulation for several residents with cognitive impairments. Activities listed on the calendar were not effectively implemented, and residents were often left sitting or wandering without meaningful interaction. Staff struggled to engage residents due to limited resources and familiarity, leading to concerns from family members and a lack of tailored activities to meet residents' needs.
The facility failed to ensure the activities program was directed by a qualified professional. The current Activities Director, Staff B, lacked the necessary qualifications and certification in therapeutic activities, as confirmed by the Human Resources Director and Administrator. Staff B had been in the role for several months without meeting the job requirements, following the departure of the previous Activities Director.
The facility failed to document the completion of 12 hours of continuing competency education for five CNAs in 2023. Despite reminders sent by the HRD, a miscommunication between the HRD and ADON regarding monitoring responsibilities led to this oversight.
The facility failed to provide dignified care to two cognitively impaired residents. One resident, with a fractured wrist, was observed without a required splint, leading to discomfort and agitation during inappropriate public dressing changes by an LPN. Another resident, with dementia, was seen wandering barefoot and with mismatched socks, taking food and personal items without staff intervention. These actions compromised the residents' dignity and care.
The facility failed to maintain a clean and safe environment in the Memory Care Unit, affecting multiple rooms and the dining area. Observations included a strong odor of urine and feces, missing bathroom mirrors, exposed wires, and large holes in walls. Staff interviews revealed a lack of a Maintenance Director and outdated maintenance requests, with the Regional Maintenance Director confirming the issues.
Two residents admitted to the facility did not receive their Baseline Care Plans (BCPs) as required. One resident, with End Stage Renal Disease and Chronic Diastolic Heart Failure, and another with Chronic Obstructive Pulmonary Disease and Malignant Neoplasm of the Liver, were not provided with their BCPs, which should have included initial goals, medication summaries, and dietary instructions. Staff interviews confirmed the absence of documentation and the residents' lack of awareness of their care plans.
A resident with a skin tear on the right wrist was observed with an undated bandage, and there was no documentation of a wound care order or progress notes in the clinical records. Staff interviews confirmed the lack of documentation and physician orders, which could risk infection or worsening of the wound.
A resident with broken teeth did not receive timely dental care, including routine cleanings and partial dentures, due to a lack of coordination by the facility's Social Service Director. The resident had not seen a dental hygienist for several months and was unaware of when she would receive partial dentures, despite a dentist's recommendation. The facility's Social Worker Regional Director confirmed the absence of routine dental care and noted the lack of follow-up for necessary dental procedures.
A resident diagnosed with influenza was not placed in a private room as required by facility policy and CDC guidelines, leading to a deficiency in infection control. The resident was initially placed on contact precautions instead of droplet precautions due to miscommunication among staff, including the ADON, Unit Manager, and DON. The Regional Nurse provided guidance without consulting the facility's infection control policy, assuming the resident was asymptomatic.
The facility failed to ensure that two residents received showers as scheduled and as requested by their families. One resident with dementia and physical impairments had only one documented shower in March 2024, despite a grievance from her granddaughter. Another resident with multiple physical issues also had only one documented shower in the same period, confirming a consistent failure in providing and documenting necessary care.
Failure to Complete Individualized Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement individualized, person-centered baseline care plans within 48 hours of admission for three residents, as required by its Plan of Care Policy and Procedures. The policy, revised on 9/25/17, required that an individualized baseline plan of care be created within 48 hours of admission, including initial goals and interventions based on admission orders, physician orders, dietary orders, therapy services, social services if applicable, and other areas needed to provide effective care until the comprehensive care plan was completed. Record review for one resident admitted for rehabilitation after a fall at home showed that the baseline care plan was essentially blank, containing only the spouse’s signature on one page and lacking any initial goals, instructions, or interventions, including failure to address the resident’s history of falls or to identify goals and interventions to prevent further falls. Record review for a second resident admitted from the hospital with chest pain for rehabilitation services showed that the baseline plan of care had an incomplete first page, and while a goal for falls/safety was circled, no interventions were identified for that goal. For a third resident admitted from the hospital with acute respiratory failure with hypoxia for rehabilitation services, the baseline plan of care also had an incomplete first page, and the goals for falls/safety, oral/dental, pain, and anticoagulant use were circled without any corresponding interventions documented. In interviews, the unit manager stated that the admitting nurse was required to complete a comprehensive assessment and personalized baseline care plan at admission and that she reviewed new admissions the next day to ensure orders, assessments, and baseline care plans with goals and personalized interventions were completed. Both the unit manager and the DON confirmed, upon review, that the baseline care plans for these three residents were incomplete and did not include the required goals and interventions needed to meet residents’ needs until the comprehensive plans of care were completed.
Failure to Provide Ordered Rehabilitation Therapy Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered specialized rehabilitative services, specifically occupational, physical, and speech therapy evaluations and treatment, for one resident admitted for rehabilitation following a closed head injury. The resident was discharged from the hospital to the facility on 1/15/26 with a primary diagnosis of closed head injury and with physician orders dated 1/16/26 for OT, PT, and speech therapy evaluations and to treat as indicated. The Medical Certification for Medicaid Long-Term Care and Services and Patient Transfer Form dated 1/14/26 documented that the resident was being discharged to a skilled facility for rehabilitation. The resident’s daughter reported that her father had been hospitalized after a fall at home and that she was informed by the resident and his wife that rehabilitation therapy would not begin until 2/02/26. The Director of Therapy confirmed that although the resident was admitted with therapy orders on 1/16/26, only a wheelchair evaluation was completed on 1/16/26 and a wheelchair was provided that day. She stated that the standard practice was to complete therapy evaluations within 48 hours of admission, but in this case, the PT, OT, and speech evaluations were not performed as ordered and were instead scheduled for 2/02/26. These evaluations were not completed on 2/02/26 because the resident was sent to the hospital that day for a change in mental status. The DON confirmed that the resident had orders dated 1/16/26 for OT, PT, and speech therapy evaluations, which were acknowledged by the primary care physician on 1/21/26, and that these ordered evaluations were not completed as directed by the physician.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, which specifies regular inspection, reporting, and prevention of pest infestations. During an initial tour, surveyors observed two brown bugs crawling up the wall in an occupied resident bathroom. Staff present acknowledged the ongoing presence of pests, with a CNA stating that bugs are seen everywhere and that spraying has not resolved the issue. Multiple residents reported frequent sightings of roaches, including one who described seeing roaches nightly and another who requested a transfer due to the infestation. Staff interviews further confirmed the widespread nature of the problem, with reports of bugs in resident drawers and emerging from air-conditioning units. Review of the facility's pest sighting logs revealed repeated reports of roaches and ants across all nursing units over several months, including sightings in resident rooms, staff breakrooms, and common areas. Pest control service logs indicated treatments were performed, but also documented ongoing issues such as rodent droppings and bed bug treatments. Despite regular pest control visits, staff and maintenance personnel reported that infestations persisted and that immediate action was limited by the availability of pest control services and lack of on-site resources. The facility's failure to effectively address and resolve these pest issues resulted in an environment that was not free from pests for at least two residents.
Failure to Assign and Document Charge Nurse on All Shifts
Penalty
Summary
The facility failed to ensure that a licensed nurse was designated to serve as charge nurse on all shifts, as required. Review of daily assignment sheets for three nursing units over several days revealed that no charge nurse was documented for the 3:00 p.m. to 11:00 p.m. or 11:00 p.m. to 7:00 a.m. shifts. Staff interviews confirmed that there was confusion among nursing staff regarding who was responsible for oversight during these shifts. The Director of Nursing (DON) stated that there was no designated charge nurse at night and that all nurses worked together, while the Assistant Director of Nursing (ADON) indicated that an RN on duty at night was considered the supervisor, but this was not consistently documented on assignment sheets. Further interviews with LPN staff revealed a lack of awareness about who the evening or night supervisor was, with staff unable to identify a designated leader for those shifts. The Administrator also could not confirm who was in charge, deferring to the DON. The DON acknowledged that there was not currently a licensed nurse assigned as supervisor on the evening shifts and confirmed the lack of documentation on assignment sheets. No specific residents or patient conditions were mentioned in relation to this deficiency.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure a safe and abuse-free environment for all residents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent Physical Restraint and Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment and dementia from abuse in the form of physical restraint not required to treat medical symptoms. The incident involved two CNAs who were observed by a registered nurse holding the resident by the head, chest, arm, and feet in an attempt to keep her seated in a chair while she was agitated, screaming, and attempting to get up. The nurse intervened, instructed the CNAs to stop, and assisted the resident out of the chair. The resident was subsequently found to have bruising on her chest, right arm, and hand, as well as on her left forearm and hand. Staff interviews and record reviews confirmed that the CNAs physically restrained the resident, which was not permitted by facility policy and was not required for the resident's medical condition. The facility's policy defines abuse as the willful infliction of injury, and the DON and Administrator acknowledged that physically holding a resident in this manner would be considered a restraint and potentially abuse. The incident was under investigation at the time of the report, and the Administrator indicated it was being treated as an abuse case.
Failure to Provide Required Transfer/Discharge Documentation and Notification
Penalty
Summary
The facility failed to ensure that required documentation and notifications were completed for residents who were transferred or discharged. Specifically, for three residents reviewed, there was no evidence in the medical records of proper documentation regarding the reasons for transfer or discharge, nor were there written notifications provided to the residents or their representatives as required by facility policy and federal/state regulations. The facility policy mandates that in cases of transfer or discharge, especially those initiated by the facility, documentation must be present in the resident's medical record, and written notice must be given to the resident and their representative, including information about appeal rights and bed-hold policies. For one resident, there were no progress notes indicating the reason for transfer or the resident's destination after discharge. The DON and Administrator were unable to provide documentation such as bed-hold or transfer/discharge notices, and there was confusion regarding the resident's readiness to return and the facility's bed availability. Another resident was sent to the hospital for chest pain and subsequently discharged, but the chart lacked further documentation about the resident's status or the facility's decision-making process. Dialogue between the hospital and facility indicated the facility declined to accept the resident back, citing care needs and safety concerns, but no formal notice of discharge was issued. A third resident was sent to the hospital due to a medical issue, but again, there was no documentation in the chart regarding the outcome or any bed-hold notice. Staff interviews confirmed that required documentation, including bed-hold notifications, was not found for any of the three residents. The lack of documentation and notification represents a failure to follow established procedures for resident transfers and discharges.
Failure to Permit Return and Provide Required Discharge Documentation After Hospitalization
Penalty
Summary
The facility failed to permit two residents to remain in or return to the facility following hospitalization, as required by federal and state regulations. For one resident, there was no documentation in the chart indicating the reason for transfer to the hospital or the subsequent discharge process. The DON stated the resident was sent to the hospital due to pain after an incident involving muscle spasticity and shaking, but could not provide required documentation such as a bed hold or transfer/discharge notice. The resident was later transferred to a long-term acute care hospital, and when ready to return, the facility did not have a bed available. The administrator and admissions coordinator could not provide clear reasons for not readmitting the resident, and there was no evidence that the facility assessed bed availability or provided the necessary notifications. For the second resident, the chart indicated a transfer to the hospital for chest pain, but there was no further documentation regarding the resident's status or discharge process. The DON and admissions coordinator gave conflicting accounts, with the DON stating the resident chose to transfer to another facility, while the admissions coordinator referenced care needs and behavioral concerns as reasons for not accepting the resident back. Communication with the hospital revealed the facility cited care needs exceeding capacity and the resident being a danger to self and others, but the DON later stated the resident was not actually a threat and had not been involved in physical altercations. There was also no bed hold documentation or 30-day discharge notice provided for this resident. The facility's own policy requires that residents sent to acute care must be permitted to return unless specific criteria are met, and that appropriate documentation and notifications must be completed. In both cases, the facility did not follow its policy or regulatory requirements, as evidenced by missing documentation, lack of clear decision-making regarding readmission, and failure to provide required notices to the residents.
Failure to Provide Scheduled ADL Care Including Nail Care and Showers
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically nail care and showers, for two dependent residents. According to facility policy, residents are to receive assistance with bathing at least twice a week or as needed, with preferences reviewed quarterly. Documentation showed that one resident, who had severe cognitive impairment, received only four bed baths over a six-week period, with the last recorded on 6/2/25, despite scheduled shower days. Another dependent resident, who preferred showers, received only two showers in the same timeframe, with bed baths substituted despite the documented preference for showers. Observations revealed both residents had disheveled, greasy hair and long, dirty fingernails with debris under and around the nails. Staff interviews confirmed that nail care and bathing were not performed as scheduled, and there was a lack of clarity among CNAs and LPNs regarding nail care routines. No refusals for care were documented for either resident. The DON and facility administrator confirmed that nail care and showers should have been provided according to policy and resident schedules, but this was not done.
Inconsistent Meal Documentation Leads to Nutritional Deficiency
Penalty
Summary
The facility failed to ensure consistent documentation of meal intake for two residents with significant weight loss, which hindered the evaluation of nutritional interventions. Resident #3 was admitted with a history of altered mental status, dehydration, and abnormal laboratory results. Despite the Registered Dietitian (RD) implementing nutritional interventions, including adding nectar-thickened milk to meals, the resident experienced a significant weight loss of 13% over two weeks. The RD noted the family's request for an appetite stimulant and a diet change, but these were not communicated effectively to the interdisciplinary team (IDT) or documented consistently by nursing staff. Resident #9, diagnosed with alcohol dependence and alcoholic cirrhosis, also experienced significant weight fluctuations. The RD documented a significant weight loss and noted the resident's difficulty in feeding himself. Despite interventions such as fortified foods and an appetite stimulant, the resident's meal intake was inconsistently documented by Certified Nursing Assistants (CNAs), making it difficult to assess the effectiveness of the interventions. The resident's weight continued to decline, and meal refusals were not consistently reported to nursing staff. The Director of Nursing (DON) confirmed the lack of consistent documentation and communication regarding the residents' meal intakes and weight loss. The DON was unaware of the documentation lapses and the failure to capture Resident #9's weight loss on the Roster Matrix. The facility's internal processes, including in-service training for CNAs, were not effectively ensuring compliance with documentation requirements, contributing to the deficiency in monitoring and addressing the residents' nutritional needs.
Failure to Prevent Falls and Provide Adequate Supervision
Penalty
Summary
The facility failed to implement a systemic approach to identify risk factors and provide adequate supervision to prevent avoidable falls with serious injuries for three residents. Resident #10, who had a history of falls and severe cognitive impairment, experienced a fall resulting in a nasal fracture. The fall investigation noted the resident was found face down in the hallway, and the root causes were identified as lack of safety awareness, anxiety, and an unclear walkway. Despite the resident's claim of being pushed, the facility did not document this as a potential cause, and the care plan was only updated to include staff education on keeping walkways clear. Resident #69, with diagnoses including vascular dementia and Alzheimer's disease, sustained a fall resulting in a wrist fracture requiring surgery. The resident was observed wandering unsupervised, and the care plan lacked specific measures for supervision to prevent falls. The family expressed concerns about the lack of supervision and repeated falls, including previous incidents of broken fingers and a hip fracture. The facility's incident log revealed 28 falls in the secured unit, but the care plan did not address the need for adequate supervision. Resident #30, admitted with diagnoses including dementia and repeated falls, experienced multiple falls resulting in injuries, including a subarachnoid hemorrhage. The care plan identified the resident as a fall risk due to wandering and confusion but failed to implement specific interventions for fall prevention. Staff interviews indicated the resident wandered frequently, and there were no fall interventions in place. The Director of Nursing acknowledged the oversight in implementing fall interventions for Resident #30.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a safe and sanitary manner, as observed during a kitchen tour. Unlabeled and undated food items, including meat in a storage bag, were found in the walk-in refrigerator, and the Dietary Manager could not identify the food without labels. Additionally, the dishwasher, originally a high-temperature model, was converted to a low-temperature sanitizing dishwasher, but staff were not trained to use test strips to ensure the appropriate amount of sanitizing agent was present. The dishwasher logs showed no entries for sanitizer levels, only water temperature, and the test strip bottle's label was worn, making it impossible to verify the results. Further observations revealed two large black plastic covers covered in dust and debris stored on the bottom shelf of the steam table, which were used to cover clean plates. The ceiling tiles and air conditioning vents over the food preparation area and clean dish storage were dirty, dusty, and covered in black bio growth. The Maintenance Director, who had been employed for three months, admitted that the vents and tiles were not cleaned monthly as required, due to being too busy. These deficiencies indicate a lack of adherence to the facility's policies on food storage and equipment maintenance, compromising the sanitary conditions necessary for safe food handling.
Deficiency in Activity Program for Memory Care Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the individual needs and preferences of residents in the secured memory care unit. This deficiency was observed in six residents who were not engaged in meaningful activities that aligned with their interests and cognitive abilities. The activity calendar for the unit listed activities such as courtyard time, hydration, and socializing, but these were not effectively implemented. For instance, courtyard time had not occurred in a month due to weather conditions, and the activity calendar was not updated to reflect alternative activities. Several residents, including those with severe cognitive impairments and a history of wandering, were observed without structured activities or staff intervention. Residents were often left sitting in the dining room with the television on, but not engaged in any meaningful way. Some residents were seen wandering the unit without redirection or involvement in activities that could provide cognitive stimulation or social interaction. Staff interviews revealed that the activity aids were not familiar with the residents and struggled to engage them in the planned activities. The facility's failure to provide appropriate activities was further highlighted by family members' concerns and staff admissions. Family members noted the lack of activities and engagement for their loved ones, while staff acknowledged the challenges in implementing the activity calendar due to limited resources and staffing. The Activity Director confirmed that activities were not being conducted as scheduled, particularly for residents who wandered, and there was no specific program to address their needs. This lack of structured activities and engagement contributed to the residents' aimless wandering and lack of stimulation, failing to meet their physical, mental, and psychosocial well-being needs.
Unqualified Activities Director in LTC Facility
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by federal, state, and local standards. The job description for the Director of Therapeutic and Recreational Services specifies that the individual must possess a minimum of a bachelor's degree in therapeutic recreation or equivalent training/experience, along with at least two years of experience in therapeutic recreation. However, upon review, it was found that the current Activities Director, referred to as Staff B, did not have the necessary qualifications or certification in therapeutic activities. The Human Resources Director confirmed that Staff B had been acting as the Activities Director for several months without the required qualifications. Staff B was in training to obtain her certification and was working under the supervision of the Administrator. Despite this, there was no documentation in the employee file to show that Staff B met the requirements for the position. The Administrator also confirmed that Staff B had been in the role for more than six months without the necessary qualifications, following the departure of the previous Activities Director.
Failure to Document CNA Continuing Education
Penalty
Summary
The facility failed to ensure that five Certified Nursing Aides (CNAs), identified as Staff E, N, O, P, and Q, completed the required 12 hours of continuing competency education for the year 2023. This deficiency was identified through staff interviews and a review of employee files, which revealed a lack of documentation confirming the completion of the mandatory training. The CNAs were hired between 2001 and 2021, and the absence of training documentation was confirmed by the Human Resource Director (HRD) and the Assistant Director of Nursing (ADON)/Staffing Coordinator. The HRD acknowledged sending email reminders to CNAs throughout the year to complete their mandatory training via an educational portal. However, there was a miscommunication between the HRD and the ADON regarding the responsibility for monitoring the completion of this training. The HRD believed the ADON was responsible for ensuring compliance, while the ADON assumed it was the HRD's responsibility. This lack of clarity and oversight resulted in the failure to document the completion of the required training for the CNAs in 2023.
Failure to Ensure Dignified Care for Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide care and services with respect and dignity to two cognitively impaired residents in the memory care unit. Resident #69, who was readmitted from an acute care hospital with a fractured and surgically repaired right wrist, was observed without the required dressing or splint, leading to visible swelling and bruising. Despite the resident's discomfort, an LPN administered medication audibly in front of other residents and proceeded to dress the resident's incision in the dining room, causing the resident to become agitated. The LPN blocked the resident's exit and applied an ace wrap to prevent the resident from picking at the sutures, further compromising the resident's dignity. Resident #23, diagnosed with dementia and other mental health disorders, was observed barefoot and later with mismatched socks, wandering the memory care unit without staff intervention. The resident was seen taking food from other residents' plates and personal items from their rooms without redirection from staff. A CNA acknowledged the behavior but did not consistently redirect the resident, and the Director of Nursing confirmed the resident's mismatched socks. These observations indicate a lack of appropriate care and respect for the resident's dignity and personal needs.
Facility Fails to Maintain Safe and Clean Environment in Memory Care Unit
Penalty
Summary
The facility failed to maintain a clean, safe, and comfortable environment in the Memory Care Unit, affecting 9 out of 13 rooms and the dining room. Observations revealed a strong musty odor with a foul smell of urine and feces throughout the unit. Specific issues included a thick black substance on a ceiling tile, missing bathroom mirrors, exposed wires, missing closet doors, broken toilet paper holders, and large holes in walls. Photographic evidence was obtained for many of these deficiencies. Interviews with staff revealed that there had been no Maintenance Director for some time, and the previous director did not address repair needs. The maintenance repair request log showed the last request was dated nearly two months prior to the survey, indicating a lack of timely maintenance actions. The Regional Maintenance Director confirmed the findings and acknowledged the need for addressing the identified issues.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to ensure that a Baseline Care Plan (BCP) was provided to two residents, Resident #4 and Resident #26, upon their admission. Resident #4, who was admitted from an acute care hospital with diagnoses including End Stage Renal Disease and Chronic Diastolic Heart Failure, did not receive a copy of her BCP. The Assistant Minimum Data Set (MDS) Coordinator and Unit Manager confirmed that there was no documentation indicating that Resident #4 or her legal representative received the BCP, which should have included initial goals, a summary of medications, dietary instructions, and services to be administered. Similarly, Resident #26, admitted with conditions such as Chronic Obstructive Pulmonary Disease and Malignant Neoplasm of the Liver, also did not receive a copy of her BCP. The Assistant MDS Coordinator and Unit Manager confirmed the absence of documentation for Resident #26's BCP being provided to her or her representative. The BCP was found unsigned in a binder, indicating it was not reviewed with the resident as required. Interviews with staff, including the Director of Nursing, revealed that the admitting nurse was responsible for completing and reviewing the BCP with the resident at the time of admission. However, this process was not followed for Residents #4 and #26, as confirmed by the lack of documentation and the residents' statements that they did not receive their BCPs or attend an initial care plan meeting.
Failure to Document and Implement Wound Care Orders
Penalty
Summary
The facility failed to implement resident-directed care and treatment per physician order and professional standards of practice for a resident reviewed for wound care. The facility's policy required licensed nurses to complete weekly skin evaluations and document any skin impairments. However, during observations, a resident was found with a bandage on the right wrist that was not documented in the clinical records. The bandage was dated two days prior to the observation, and there was no documentation of a wound care order or progress notes describing the wound's condition or stage of healing. Interviews with staff revealed that the resident had a skin tear on the right wrist, but there was no documentation or physician orders for wound care in the electronic clinical record. The Director of Nursing confirmed the lack of documentation and acknowledged the absence of a wound care order. This oversight in documentation and failure to follow the facility's policy could place the resident at risk for infection or worsening of the wound.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide appropriate dental care and services for a resident with broken teeth. The resident reported not having seen a dental hygienist for several months and was unaware of when she would receive partial dentures to replace her broken teeth, despite being informed by a dentist months prior that she could get them. The resident's medical record indicated she was last seen by a dental hygienist in late 2022, and there was no documentation of routine dental cleaning in 2024. The facility's Social Worker Regional Director (SWRD) confirmed the lack of routine dental care and noted the absence of a full-time Social Service Director (SSD) to coordinate ancillary services, including dental care. The SWRD's review of the resident's medical record and communication with the dentist's office revealed that the resident had been seen by a dentist in April 2024, who documented the resident's interest in tooth extractions and partial dentures. However, there was no evidence that the SSD had followed up with the dentist's office for approval of the extractions and partial dentures. Additionally, there was no documentation of coordination between the SSD, the dentist, and the resident to ensure timely receipt of the partial dentures, as required by the facility's policies and procedures.
Failure to Implement Appropriate Transmission-Based Precautions
Penalty
Summary
The facility failed to implement appropriate transmission-based precautions for a resident diagnosed with influenza, leading to a deficiency in infection prevention and control. The resident, who had a history of diabetes, dementia, schizoaffective disorder, and hypertension, was admitted to the facility and later sent to the hospital for evaluation of chest pain, cough, and elevated blood sugar. Upon returning with a diagnosis of parainfluenza, the resident was placed in a double occupancy room instead of a private room, contrary to the facility's policy and CDC guidelines. The resident was initially placed on contact precautions, and it was not until several days later that droplet precautions were ordered by a physician. Miscommunication among the facility's staff contributed to the failure to implement the correct precautions. The Assistant Director of Nursing/Infection Preventionist acknowledged that the resident should have been placed on droplet precautions and in a private room, but this did not occur due to a breakdown in communication between the Unit Manager and the Director of Nursing. The Director of Nursing was unaware of the need for a private room, and the Regional Nurse provided guidance based on the assumption that the resident was asymptomatic, without referring to the facility's infection control policy. This series of actions and inactions led to the deficiency in managing the resident's transmission-based precautions.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that two residents received showers as scheduled and as requested by their families. Resident #159, who has a history of dementia, muscle weakness, dysphagia, and difficulty walking, was admitted to the facility and required partial assistance for showering. Despite a written grievance from her granddaughter on 3/12/24, stating that Resident #159 had not received a shower since admission, the facility only documented one shower for her in March 2024. The Director of Nursing acknowledged that if the showers were not documented, they were not done, indicating a failure in both providing and documenting the necessary care. Similarly, Resident #7, who has a history of muscle weakness, chronic pain, difficulty walking, unsteadiness, abnormalities with gait and mobility, and repeated falls, also required partial assistance for bathing. The facility's documentation showed that Resident #7 had only one shower in March 2024. The resident confirmed that he had not received a shower for a week prior to the survey date. This indicates a consistent failure by the facility to provide and document the required showers for residents, leading to deficiencies in their care.
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Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
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.
