Aviata At North Florida
Inspection history, citations, penalties and survey trends for this long-term care facility in Gainesville, Florida.
- Location
- 6700 Nw 10th Place, Gainesville, Florida 32605
- CMS Provider Number
- 105460
- Inspections on file
- 33
- Latest survey
- October 10, 2025
- Citations (last 12 mo.)
- 8 (3 serious)
Citation history
Health deficiencies cited at Aviata At North Florida during CMS and state inspections, most recent first.
A facility failed to ensure that nurses had the required IV certification and did not follow protocols for IV medication administration, physician notification, and obtaining stat orders. As a result, a resident with a complex medical history missed multiple doses of critical IV antibiotics, received an incorrect dose, and developed altered mental status, leading to hospital admission for sepsis. Staff interviews revealed confusion about medication availability, equipment use, and communication with providers, while documentation was incomplete or missing.
A resident with a complex medical history, including osteomyelitis and recent surgery, did not receive prescribed IV antibiotics as ordered, resulting in missed doses and an incorrect dose. Nursing staff failed to follow medication administration protocols, did not properly notify providers or document actions, and were unclear about procedures for obtaining medications and equipment. The resident developed altered mental status and was later hospitalized with sepsis and subtherapeutic antibiotic levels.
A resident with a history of osteomyelitis and other complex conditions was not administered physician-ordered IV antibiotics as prescribed, resulting in multiple missed doses and an incorrect initial dose. LPNs and other staff failed to follow facility policy for obtaining urgently needed medications, did not document missed doses or provider notifications, and did not utilize available pharmacy stat delivery options. The resident developed altered mental status and was transferred to the hospital, where sepsis was diagnosed and the lack of proper antibiotic administration was identified as a contributing factor.
A resident with multiple complex medical conditions experienced several episodes of low blood pressure, but neither the physician nor the resident's representative were notified as required. Staff interviews confirmed that no notifications or follow-up actions were taken, and documentation was lacking, despite facility policy mandating prompt notification and recordkeeping for significant changes in condition.
Two residents with midline and central venous access devices did not receive dressing changes and flushing according to professional standards. One resident's midline catheter dressing was not changed as ordered, and the insertion site was obscured by gauze. An LPN administered IV medications without confirming catheter patency. Another resident's PICC line dressing was overdue for change, and a dressing change was falsely documented as completed. Facility policies for dressing changes and catheter patency checks were not followed.
A resident with multiple medical conditions received Metoprolol despite physician-ordered parameters to hold the medication for low systolic blood pressure. Medication records showed repeated administration of the drug when blood pressure readings were below the specified threshold. Interviews with LPNs revealed a lack of adherence to the parameters, and facility policy requiring medications to be given as prescribed was not followed.
The facility did not ensure accurate documentation for IV therapy and medication administration for three residents. One resident's IV insertion and care were not recorded, another resident's IV removal was undocumented, and a third resident's missed IV antibiotic doses lacked corresponding nursing notes. LPNs and the DON confirmed that required documentation and provider notifications were not completed as per facility policy.
Two residents with chronic pain conditions did not receive scheduled opioid pain medications as ordered, with an LPN omitting doses because the residents were asleep. Medication administration records confirmed multiple missed doses, and both residents reported not receiving their pain medication as prescribed.
The facility failed to maintain proper repair of handrails, cleanliness of resident rooms, and application of protective pipe coverings. Missing handrail caps exposed jagged metal, and a resident's room was not regularly cleaned, with debris observed on the floor. The Maintenance Director and Environmental Services Manager acknowledged these issues, but they were not prioritized.
The facility failed to complete accurate Level I PASRR screens for two residents with serious mental disorders. One resident's PASRR did not document their diagnoses of depression, anxiety disorder, and bipolar disorder, while another resident's PASRR lacked documentation of schizoaffective disorder and adjustment disorder with anxiety. The DON confirmed the omissions and that no revised PASRRs were completed.
The facility failed to administer oxygen therapy as ordered for three residents, with incorrect flow rates observed. Additionally, respiratory masks for three residents were improperly stored, either left unbagged or on the floor, contrary to facility policy. Staff confirmed these discrepancies, and the DON emphasized the expectation for adherence to orders and proper storage protocols.
A facility failed to ensure the accuracy of an MDS assessment for a resident with a complex medical history, including sepsis and cellulitis. The resident was prescribed Rifaximin, an antibiotic, but the MDS did not reflect this under Section N - Medications. This inaccuracy was confirmed by the ADON and the MDS Coordinator during interviews.
A resident with hemiplegia and contractures did not receive necessary nail care, resulting in overgrown nails pressing into their palms. Despite the care plan and facility policy requiring regular nail maintenance, staff interviews revealed a lack of adherence to these guidelines.
A facility failed to provide proper wound care to a resident, who had multiple diagnoses including a skin infection and necrotizing fasciitis. The wound care nurse did not follow the correct wound care orders and failed to document the wound's size and condition as required. The Director of Nursing expected updated orders after physician appointments, but this was not done, leading to inconsistencies in care.
The facility failed to provide necessary lab services for two residents, impacting medication management. A resident on Depakote had no documented orders or results for required Depakote and ammonia levels, while another resident on Atorvastatin lacked lipid panel results since early 2024. Communication gaps and ineffective policy implementation contributed to these deficiencies.
The facility failed to store food items according to professional standards, with a brown buildup found in the Emergency Food Storage room and temperature issues in the freezer. The Food Services Manager was unaware of the buildup's origin, and the Maintenance Director was not informed of the issues. The facility's policy on maintenance was not followed, leading to lapses in communication and adherence.
The facility failed to ensure proper PPE use during medication administration and wound care, leading to potential infection control breaches. An LPN did not wear a gown while administering medication to a resident under enhanced barrier precautions, and another LPN did not perform hand hygiene between glove changes during wound care. These actions were contrary to the facility's infection control policies.
A resident with type 1 diabetes experienced medical neglect when the facility failed to implement insulin administration policies. The resident's blood sugar was critically high, and despite refusing medications until receiving proper insulin, staff failed to communicate or document new orders. The resident called 911 twice, eventually being hospitalized with Diabetic Ketoacidosis. Interviews revealed a lack of communication and adherence to professional standards, leading to Immediate Jeopardy.
A resident with type 1 diabetes experienced a critical incident due to the facility's failure to administer insulin according to professional standards. The resident's blood sugar was recorded at 552, and despite notifying the on-call provider, the new insulin orders were not communicated or documented. The resident called 911 twice, expressing concerns about incorrect insulin administration, and was later hospitalized with Diabetic Ketoacidosis. Interviews revealed a lack of communication and documentation, leading to a determination of Immediate Jeopardy.
A resident with Type 1 Diabetes Mellitus experienced a critical incident due to the facility's failure to implement medical neglect policies and ensure proper insulin administration. The resident's blood sugar level was 552, and despite new orders for increased insulin, the orders were not communicated or documented. The resident called 911 twice, resulting in hospitalization for Diabetic Ketoacidosis. Interviews revealed communication and documentation failures among staff, and the facility did not promptly address the incident or follow abuse and neglect policies.
A resident with type 1 diabetes experienced a critical care deficiency due to the facility's failure to manage insulin administration and communication effectively. The resident's high blood sugar was not properly addressed, leading to a hospital admission for Diabetic Ketoacidosis. Staff failed to document and communicate new insulin orders, and there was a lack of reassessment and follow-up, resulting in neglect.
A resident with Type 1 Diabetes Mellitus experienced neglect due to the facility's failure to implement policies and procedures. The resident's high blood sugar was not properly addressed, and communication breakdowns led to a lack of appropriate medical intervention. The resident eventually called 911 and was hospitalized with diabetic ketoacidosis. Staff failed to document and communicate effectively, and the facility did not follow its abuse and neglect policies.
A resident with multiple medical conditions refused medications until receiving proper insulin, but staff failed to document physician orders and used personal cell phones to communicate sensitive information. Despite facility policies prohibiting such actions, staff routinely used personal devices to share PHI, compromising resident confidentiality.
Failure to Ensure Staff Competency and Adherence to IV Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the appropriate competencies and certifications to safely administer intravenous (IV) medications, and did not follow established policies and procedures for IV medication administration, physician notification, and obtaining stat orders for medication and equipment. Specifically, two of six reviewed LPNs did not have the required IV certification to administer IV medications, and four of six reviewed LPNs did not adhere to the facility's protocols for IV medication administration. This resulted in multiple missed and incorrect doses of critical antibiotics for residents requiring IV therapy. One resident, admitted with a complex medical history including subacute osteomyelitis, spina bifida occulta, hydrocephalus, paraplegia, and other significant conditions, was ordered to receive Vancomycin 1500 mg IV every eight hours for infection. The resident received an incorrect initial dose of Vancomycin and subsequently missed eight consecutive doses over several days. Documentation and interviews revealed that staff were uncertain about medication availability, IV pump functionality, and the process for obtaining stat deliveries from the pharmacy. There was a lack of timely physician notification and inadequate documentation of missed doses and provider communications. The resident developed altered mental status, which was first identified by a family member, and was later transferred to the hospital where he was diagnosed with sepsis, with hospital records noting subtherapeutic vancomycin levels and missed antibiotic doses as contributing factors. Interviews with staff, pharmacy representatives, and providers highlighted confusion regarding medication administration responsibilities, stat order procedures, and the use of available resources such as the automated medication dispensing machine and IV pumps. The DON and medical providers confirmed that they were not appropriately notified of missed medications or equipment issues. The facility's failure to ensure staff competency and adherence to medication administration protocols resulted in significant lapses in care, including missed and incorrect antibiotic doses, delayed treatment, and a subsequent hospital admission for sepsis.
Failure to Administer Prescribed IV Antibiotics and Ensure Staff Competency
Penalty
Summary
The facility failed to protect a resident from medical neglect by not ensuring the administration of prescribed intravenous (IV) antibiotics according to physician orders. The resident, who had a complex medical history including subacute osteomyelitis, spina bifida occulta, hydrocephalus, paraplegia, and a recent surgical intervention, was admitted with orders for Vancomycin 1500 mg IV every 8 hours and Cefepime 1 g IV every 8 hours. Despite these orders, the resident received an incorrect dose of Vancomycin (1000 mg instead of 1500 mg) and subsequently missed eight consecutive doses of Vancomycin over several days. There were also missed doses of Cefepime. Documentation and interviews revealed confusion among nursing staff regarding medication availability, order entry, and the process for obtaining stat deliveries or alternative medications from the pharmacy. Nursing staff failed to follow facility policies and procedures for medication administration, physician notification, and documentation. Several nurses reported uncertainty about whether medications could be administered without a pump, whether stat deliveries could be requested, and whether alternative sources for medications or equipment were available. There was a lack of timely communication with providers regarding missed doses, and documentation of provider notifications and orders was inconsistent or absent. The pharmacy confirmed that stat deliveries and replacement IV pumps were available upon request, but staff did not utilize these options appropriately. Additionally, there were concerns about staff competency, including whether nurses had the appropriate IV certification to administer the medications safely. The resident began to exhibit a change in condition, including altered mental status, which was first identified by a family member. Despite the family member's concerns and requests for hospital transfer, facility staff did not recognize or respond to the change in condition in a timely manner. When the resident was eventually transferred to the hospital, he was diagnosed with sepsis and found to have subtherapeutic Vancomycin levels, as well as evidence of ongoing infection and abscess formation. Interviews with facility leadership and providers confirmed that the expected processes for medication administration, provider notification, and documentation were not followed, resulting in significant medication errors and harm to the resident.
Failure to Administer Ordered IV Antibiotics Resulting in Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering physician-ordered intravenous (IV) antibiotics as prescribed. The resident, who had a complex medical history including subacute osteomyelitis, spina bifida occulta, hydrocephalus, paraplegia, and other conditions, was admitted with orders for Vancomycin 1500 mg IV every 8 hours and Cefepime 1 g IV every 8 hours. Despite these orders, the resident received an incorrect initial dose of Vancomycin (1000 mg instead of 1500 mg) and subsequently missed eight consecutive doses of Vancomycin over several days. There were also missed doses of Cefepime. Documentation and interviews revealed confusion and lack of clarity among nursing staff regarding medication availability, administration times, and communication with pharmacy and providers. Multiple staff interviews indicated that medication orders were not promptly entered or administered due to issues such as medication and pump availability, lack of stat delivery requests, and unclear communication with pharmacy and providers. Nurses reported uncertainty about the process for obtaining urgently needed medications and did not consistently document missed doses or provider notifications. The pharmacy confirmed that stat deliveries and replacement IV pumps were available upon request, but staff did not utilize these options effectively. Facility policy required immediate action and provider notification when medications were unavailable, but these procedures were not followed. As a result of the missed antibiotic doses, the resident experienced a change in condition, including altered mental status, and was subsequently transferred to the hospital, where he was diagnosed with sepsis. Hospital records and provider notes indicated that the lack of proper antibiotic administration contributed to the resident's acute condition. The facility's failure to administer essential antibiotics as ordered, document actions taken, and communicate effectively with pharmacy and providers led to significant harm and was identified as an Immediate Jeopardy situation.
Failure to Notify Physician and Representative of Resident's Low Blood Pressure
Penalty
Summary
The facility failed to notify a resident's representative and physician of significant changes in the resident's condition, specifically repeated episodes of low blood pressure. The resident had multiple complex diagnoses, including pneumonia, COPD with acute exacerbation, respiratory failure, dehydration, and hypertension. On several occasions, the resident's blood pressure readings were notably low, with values in the 80s/40s-60s mmHg range. Despite these abnormal findings, there was no documentation in the nursing progress notes that the resident's representative or physician were notified of these changes on the dates the low blood pressures were recorded. Interviews with facility staff and the resident's representative confirmed that no notifications were made regarding the low blood pressure readings. The DON acknowledged that staff are expected to notify the physician and representative of such changes and document these actions, but this was not done. The LPN involved admitted to not notifying the representative or provider and did not recheck the blood pressure. Both the physician and APRN stated they were not informed of the low blood pressure episodes and emphasized the need for notification and follow-up. The facility's policy requires prompt notification and documentation when there is a significant change in a resident's condition, which was not followed in this case.
Failure to Follow IV Catheter Dressing and Flushing Protocols
Penalty
Summary
The facility failed to ensure that midline and central venous access device dressings and flushing were completed according to professional standards of practice for two residents receiving intravenous therapy. For one resident with a midline catheter for IV antibiotics, the dressing was not changed 24 hours after insertion as ordered, and gauze was placed under the transparent dressing, preventing observation of the insertion site. The medical record lacked documentation of the required dressing change, and the resident reported the dressing had not been changed since insertion. During medication administration, an LPN failed to check for blood return to confirm catheter patency before administering saline and antibiotics, contrary to facility policy. For another resident with a peripherally inserted central catheter (PICC), the dressing was not changed as scheduled, with the dressing date indicating it was overdue. The medication administration record documented a dressing change that staff later admitted was not performed, and the staff member acknowledged the documentation was inaccurate. Facility policies required dressing changes at specific intervals and confirmation of catheter patency before medication administration, but these were not followed for the residents involved.
Failure to Follow Medication Parameters for Antihypertensive Administration
Penalty
Summary
The facility failed to ensure that physician-ordered parameters for antihypertensive medication administration were followed for a resident with multiple complex medical conditions, including hypertension, respiratory failure, and hypercalcemia. The physician's order specified that Metoprolol should be held if the resident's systolic blood pressure (SBP) was less than 110 or heart rate (HR) was less than 70. Despite these clear parameters, medication administration records showed that Metoprolol was given on multiple occasions when the resident's SBP was below the ordered threshold, with documented readings as low as 80/48. Interviews with several LPNs revealed uncertainty or lack of recall regarding adherence to the medication parameters, and some staff indicated they would have held the medication if aware of low blood pressure or the specific parameters. The DON and prescribing providers confirmed that medications should not be administered outside of ordered parameters and that they were not notified of these occurrences. Facility policy required medications to be administered as prescribed, including adherence to any parameters, but this was not followed in the resident's case.
Failure to Document IV Therapy and Medication Administration
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical records for three residents who received intravenous (IV) therapy. For one resident with multiple diagnoses including pneumonia, respiratory failure, and dehydration, there was a physician order for peripheral IV insertion, but no documentation was found in the nursing progress notes regarding the insertion, site, or care of the IV. The DON confirmed that documentation should have included details such as the location of the IV, number of attempts, success of the procedure, fluids administered, and site condition, but these were missing. Nursing staff interviews revealed confusion about the presence of orders and a lack of documentation regarding IV care and communication with the resident's representative. Another resident, admitted with acute osteomyelitis, diabetes, and a history of stroke, had documentation indicating a peripheral IV was present and a physician order for its removal. However, there were no nursing progress notes documenting the removal of the IV during the relevant period. This lack of documentation failed to meet the facility's own policy requirements for recording vascular access procedures and care. A third resident, admitted with complex medical conditions including osteomyelitis, spina bifida, and paraplegia, had physician orders for IV antibiotics. The Medication Administration Record (MAR) showed multiple missed doses of vancomycin and cefepime, with chart codes indicating to see nurses' notes, but the corresponding nursing notes were absent. Interviews with LPNs revealed that medication orders were not entered promptly, medications were not available, and provider notifications were either not made or not documented. Staff acknowledged that they should have documented provider notifications and actions taken regarding missed medications, but this was not done.
Failure to Administer Scheduled Pain Medication as Ordered
Penalty
Summary
The facility failed to provide adequate pain management for two residents who were prescribed opioid pain medications. One resident, admitted with multiple diagnoses including bilateral above-knee amputations, Parkinson's disease, and diabetic polyneuropathy, reported not receiving scheduled oxycodone doses every four hours as ordered by the physician. Medication administration records confirmed missed doses on several dates, and the resident stated that staff did not wake him to administer the medication. The resident's care plan specifically included administering analgesia as per orders. Another resident, with diagnoses including paraplegia, chronic pain, and major depressive disorder, also did not receive scheduled oxycodone-acetaminophen doses as ordered for pain rated 7-10. Medication records showed missed doses, and the resident reported not receiving the medication and that staff did not address his concerns. Interviews with the Assistant Director of Nursing and the LPN involved revealed that the LPN did not administer the medications because the residents were asleep, and this action was not in accordance with physician orders.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to ensure the proper repair and maintenance of handrails in two wings, cleanliness of resident rooms, and the application of protective pipe apron coverings under the sink in a resident's room. During a tour, it was observed that several handrail caps were missing in both the 100 and 200 halls, leaving jagged metal exposed. The Maintenance Director acknowledged the issue but stated it was not a priority, while the Administrator recognized it as a safety concern. Additionally, the protective pipe apron covering under the sink in a resident's bathroom was repeatedly found on the floor over several days, despite the Environmental Services Manager indicating that staff had been shown how to replace it. Furthermore, a resident's room was observed to have a significant amount of debris, napkins, and crumbs on the floor on multiple occasions. The resident expressed that their room was not swept regularly. The Environmental Service Manager stated that the expectation was for resident rooms and floors to be swept as a priority. The facility's policy on General Hospitality Services mandates daily cleaning of resident rooms, including dust mopping and wet mopping floors with a disinfectant solution, and dusting furniture. However, these procedures were not followed, contributing to the deficiency.
Inaccurate PASRR Screens for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure accurate Level I Preadmission Screening and Resident Review (PASRR) screens were completed for two residents diagnosed with serious mental disorders. Resident #18's Level I PASRR, dated 12/24/2024, did not document any mental illness in Section I: PASRR Screen Decision-Making, despite the resident being admitted with diagnoses of depression, anxiety disorder, and bipolar disorder, all with onset dates of 12/24/2024. Similarly, Resident #77's Level I PASRR, dated 4/22/2024, lacked documentation of mental illness, even though the resident was admitted with schizoaffective disorder and adjustment disorder with anxiety. The Director of Nursing confirmed during an interview that the mental health diagnoses for both residents had not been included in their preadmission screening and resident reviews, and no revised PASRRs had been completed to document these diagnoses.
Deficiencies in Oxygen Therapy and Respiratory Equipment Storage
Penalty
Summary
The facility failed to provide oxygen therapy as ordered for three residents. Resident #4 was observed receiving oxygen at a flow rate of 3.5 liters per minute, contrary to the physician's order of 2 liters per minute. Staff K, an RN, confirmed the incorrect setting and acknowledged that the flow rate should be checked at the beginning of each shift. Similarly, Resident #10 was receiving oxygen at 2.5 liters per minute, despite a physician's order for 4 liters per minute as needed. Staff B, an LPN, confirmed the discrepancy, and the DON expressed the expectation that orders should be followed. Additionally, the facility failed to properly store respiratory masks for three residents. Resident #83's nebulizer mask was repeatedly observed on the bedside table without a protective bag, which Staff J, an LPN, confirmed was against protocol. Resident #18's nebulizer mask was found on the floor multiple times, and Staff J acknowledged it should be stored in a plastic bag. The DON reiterated the expectation for masks to be kept in bags. Resident #17's nebulizer unit and tubing were found without a date label and not stored in a bag, which Staff G, an LPN, confirmed should have been done. The facility's policies on oxygen therapy and infection prevention were not adhered to, as evidenced by the improper oxygen flow rates and inadequate storage of respiratory equipment. The facility's policy required oxygen therapy to be administered as ordered by the physician and for respiratory equipment to be stored in plastic bags with date labels to prevent infection. These lapses in following established procedures contributed to the deficiencies observed during the survey.
Inaccurate MDS Assessment for Antibiotic Use
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident, leading to a deficiency. The resident, who had a complex medical history including sepsis, cellulitis, urinary tract infection, and other conditions, was prescribed Rifaximin, an antibiotic, as per a physician's order. However, the MDS assessment did not reflect that the resident was receiving antibiotics under Section N - Medications. This discrepancy was confirmed during interviews with the Assistant Director of Nursing and the MDS Coordinator, both of whom acknowledged the inaccuracy of the assessment.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as Resident #12, who was unable to perform activities of daily living due to medical conditions including hemiplegia, hemiparesis, dysarthria, and muscle contractures. Observations on two separate occasions revealed that the resident's nails were overgrown, curling, and had a brown substance underneath, causing them to press into the palms of both hands. Despite the resident's care plan specifying that nail care should be performed on bath days and as necessary, this was not adhered to. Interviews with staff members, including a CNA, an LPN, a Restorative CNA, and the Director of Nursing, confirmed that the responsibility for nail care was understood but not executed. The CNA admitted to not having cut the resident's nails, while the Restorative CNA had repeatedly informed other CNAs about the need for nail care. The facility's policy on nail care, which includes trimming and cleaning nails, was not followed, leading to the deficiency observed by the surveyors.
Failure to Adhere to Wound Care Orders and Documentation
Penalty
Summary
The facility failed to provide wound care to a resident in accordance with professional standards of practice. The resident, who was admitted with multiple diagnoses including a local infection of the skin, cutaneous abscess, type 2 diabetes mellitus, polyneuropathy, and necrotizing fasciitis, had specific wound care orders from a hospital discharge and subsequent orders from a wound care provider. However, there was a lack of consistency and adherence to these orders. The wound care nurse admitted to not following the correct wound care orders and failing to document the wound's size and condition as required by the facility's policy. The deficiency was further compounded by the lack of updated orders following the resident's physician appointments, as expected by the Director of Nursing. The facility's policy required weekly documentation of non-pressure skin conditions, which was not adhered to, as evidenced by missing wound measurements on several dates. The wound care nurse acknowledged the oversight in documentation and order management, which contributed to the deficiency in providing appropriate wound care to the resident.
Failure to Provide Timely Laboratory Services for Residents
Penalty
Summary
The facility failed to provide necessary laboratory services for two residents, leading to deficiencies in medication management. Resident #20, who was admitted with severe dementia, major depressive disorder, and other conditions, was prescribed Depakote for mood instability. The Psychiatric Services Provider recommended monitoring Depakote and ammonia levels, but no orders for these tests were documented, and no results were available. The Psychiatric Services Provider acknowledged issues with obtaining ammonia levels due to them being send-out labs, and the Director of Nursing (DON) noted a communication gap in translating psychiatric notes into actionable lab orders. Resident #35, diagnosed with hyperlipidemia, hypertension, heart failure, dementia, Alzheimer's disease, and major depressive disorder, was prescribed Atorvastatin and required a lipid panel every 180 days. However, no lipid panel results were documented since January 2024, despite an active physician order. The DON admitted to previous issues with the lab company but emphasized the expectation to follow physician orders. The facility's policies on drug regimen review and physician orders were not effectively implemented, contributing to the failure in providing timely laboratory services.
Food Storage and Maintenance Deficiencies
Penalty
Summary
The facility failed to store food items in accordance with professional standards, as observed during a kitchen tour. A brown buildup was found on the floor of the Emergency Food Storage room under a food storage crate, located over a floor drain. The Food Services Manager, who had been in the position for seven months, was unaware of the buildup's origin and mentioned that the area was not frequently visited. Additionally, ceiling vents in the emergency food storage room and over the food preparation area had a dark substance around their perimeters, with some areas showing cracked and peeling material. The Maintenance Director was not informed of these issues and noted that the brown buildup was dry, suggesting it might have been from a previous drain overflow. The facility's Freezer Temperature Log for January 2025 showed temperatures above the freezing point on multiple occasions, with no corrective actions documented. The District Manager for Food and Nutrition Services stated that food was moved from the emergency food supply room after discovering the drain, and the freezer's contents were relocated due to temperature issues. The facility's policy on maintenance emphasized preventative maintenance and prompt action for repairs, but the Director of Environmental Services was not informed of the issues, indicating a lapse in communication and adherence to the policy.
Infection Control Breaches in PPE Usage
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) during medication administration and wound care, leading to potential infection control breaches. In the first instance, a Licensed Practical Nurse (LPN) prepared medications for a resident with a gastrostomy tube, who was under enhanced barrier precautions. Despite signage indicating the need for both gloves and a gown for high-contact activities, the LPN administered medication using the feeding tube without donning a gown. The Assistant Director of Nursing confirmed that the expectation was for staff to adhere to the enhanced barrier precaution policy, which includes wearing a gown. In a separate incident, another LPN, serving as a Wound Care Nurse, failed to perform hand hygiene between glove changes during wound care for a resident. After rinsing the resident's groin wound, the nurse changed gloves without washing hands, contrary to the facility's policy that requires handwashing after glove removal. The Director of Nursing stated that the expectation is for staff to wash hands before donning gloves and after doffing them, regardless of the task being performed. These lapses in infection control practices were observed and documented, highlighting deficiencies in adherence to established protocols.
Failure to Implement Insulin Administration Policies Leads to Resident's Hospitalization
Penalty
Summary
The facility failed to protect a resident from medical neglect by not implementing policies and procedures for insulin administration. On the morning of October 6, 2024, a resident with a history of type 1 diabetes and other significant health issues had a blood sugar level of 552. The resident refused medications until he received the proper insulin. Staff A, an LPN, did not communicate the new insulin orders to Staff B, another LPN, nor did they transcribe these orders into the medical record. Consequently, Staff B did not follow up with the provider, reassess the resident's blood glucose, or address the need for any orders. The resident called 911 twice on the same day, with the first call being dismissed by Staff B, who instructed EMS that the resident did not need help. However, during the second call, the resident was transferred to the hospital and admitted to the ICU with a diagnosis of Diabetic Ketoacidosis (DKA). The facility's failure to implement the policy and procedure for medical neglect and ensure residents requiring insulin administration received treatment in accordance with professional standards of practice led to a determination of Immediate Jeopardy. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's condition and treatment. The Director of Nursing acknowledged that the nurse in charge did not act within professional standards of practice for treating hyperglycemia in a type 1 diabetic. The Medical Director and other medical staff indicated that the professional standard of practice would have been to recheck the blood glucose after high readings and notify the provider of the resident's refusal of treatment. The facility did not follow its abuse and neglect policies, and there was a failure to conduct a thorough investigation or implement corrective actions promptly.
Removal Plan
- The Executive Director completed a 30-day look back at all reportables to ensure proper investigation was conducted.
- The Director of Nursing completed all hospital transfers, conducted a facility wide audit of change in conditions pertaining to insulin with no additional concerns related to blood sugars.
- Education was provided to the Executive Director by the Regional President on Abuse/Neglect policy and procedure to include investigations.
- The Regional Nurse Consultant provided abuse/neglect education, as well as investigation to the nurse management staff.
- Education included: abuse/neglect policy and procedure related to neglect for failure to reassess, notify the physician, not documenting physician's orders, not documenting communication to the physician, not documenting the transfer of the resident to the hospital, not following physician orders, and lack of shift-to-shift report.
- All incidents to be called to the Regional President, Regional Director of Clinical Services, and Risk Manager with a timeline of events on any incident to determine if reportable.
- Investigations to be started immediately on any complaints or incidents.
- The grievance log was reviewed for concerns related to change of condition, insulin, abuse or neglect.
- The Director of Nursing conducted a facility wide audit of all hospital transfers and change of condition pertaining to insulin with no additional concerns related to blood sugars.
- Education was provided for all staff by the Director of Nursing/designee on the abuse neglect policy.
- Facility personnel received education related to the abuse/neglect policy to include preventing abuse, identification, protection, investigating and reporting inappropriate resident behaviors to the nurse.
- Key staff were educated on reporting process of a potential deficient practice or suspected abuse/neglect to the Quality Assurance performance Improvement (QA/PI) by notifying the Executive Director and/or the Director of Nursing.
- An Ad Hoc that included the Executive Director, Medical Director, Director of Nursing the root cause analysis was the facility failed to initiate/implement the abuse/neglect policy including a complete investigation.
- Education has been completed on licensed nurses on medical neglect, accuchecks, insulin, Type 1 and 2 diabetes, and Change of Condition policy.
- Certified Nursing Assistants and ancillary staff were also educated.
Failure to Administer Insulin Properly Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that a resident requiring insulin administration received treatment in accordance with professional standards of practice. On the morning of October 6, 2024, a resident with a history of type 1 diabetes mellitus and other significant health conditions had a blood sugar level of 552. The resident refused medications until he received the proper insulin. Staff A, an LPN, notified the on-call provider but failed to communicate the new orders to Staff B, the LPN who assumed care later that morning. Staff B did not follow up with the provider, reassess the resident's blood glucose, or address the need for any orders. The resident called 911 twice on the same day, expressing concerns about not receiving the correct insulin. Despite the resident's calls, Staff B instructed EMS that the resident did not need help. Later that night, the resident was transferred to the hospital and admitted to the ICU with a diagnosis of Diabetic Ketoacidosis. The facility's failure to implement the policy and procedure for change of condition and physician notification, along with the failure to ensure proper insulin administration, led to a determination of Immediate Jeopardy. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's condition and treatment. The Director of Nursing acknowledged that the nurse should have notified the doctor immediately when the resident refused insulin and that the orders should have been transcribed. The Medical Director and other staff members confirmed that the professional standard of practice was not followed, as the resident's blood glucose was not rechecked, and the refusal of insulin was not properly communicated to the physician.
Removal Plan
- An Ad Hoc was completed in the presence of the Executive Director, Medical Director and the Director of Nursing, to identify the root cause analysis was that the facility failed to ensure residents were free from complications of a change in condition due to not reassessing residents, not transcribing and administering ordered medication, not properly notifying the physician and not properly identifying the change in condition.
- Licensed staff were educated on the change of condition process notifying the provider of abnormal blood glucose levels, notification of change, refusal of medications, assessment and reassessments for abnormal glucose levels and other change in condition, and transcribing and administration of physician orders.
- The Director of Nursing completed a full house audit of hospital transfers and changes in conditions with no deficient practice noted related to blood sugars, insulin, and transcribing/administering.
- An in-service on the topic of abuse/neglect presented by the Regional Director of Clinical Services was provided to the nursing management staff, the Director of Clinical Services, Assistant Director of Clinical services, and two Unit Managers.
- The Executive Director received education on abuse and neglect training (reporting requirements) from the Regional President of Operations.
- Licensed staff, Certified Nursing Assistants, and ancillary staff received training on Abuse and Neglect, assessment and reassessment of residents, change-in-condition process, hospital transfer process, communication during shift-to-shift report, insulin administration, abuse/neglect identification and process and communication between staff and providers.
- Staff interviews verified receiving the training and verbalized understanding of the abuse and neglect, changes in condition policies and procedures, resident reassessment after changes in condition.
Failure to Implement Medical Neglect Policies Leads to Resident's Hospitalization
Penalty
Summary
The facility administration failed to effectively manage resources and implement policies and procedures for medical neglect and resident change of condition, leading to a critical incident involving a resident with Type 1 Diabetes Mellitus. On the morning of October 6, 2024, a resident had a blood sugar level of 552, and the on-call provider was notified. The resident refused medications until he received the proper insulin. Staff A, an LPN, did not communicate the new orders for increased insulin and sliding scale insulin coverage to Staff B, another LPN, nor were these orders transcribed into the medical record. Staff B assumed care of the resident at 7:00 AM but did not follow up with the provider, reassess the resident's blood glucose, or address the need for any orders. The resident called 911 twice, first at 6:30 PM, when EMS was instructed by Staff B that the resident did not need help, and again at 11:15 PM, leading to the resident's transfer to the hospital. The resident was admitted to the Intensive Care Unit with a diagnosis of Diabetic Ketoacidosis. The facility's failure to implement the policy and procedure for medical neglect and ensure residents requiring insulin administration received treatment in accordance with professional standards of practice resulted in a determination of Immediate Jeopardy. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's condition and treatment. The Director of Nursing acknowledged that the nurse in charge did not act within professional standards of practice for treating hyperglycemia in a type 1 diabetic. The Medical Director emphasized the importance of glucose monitoring and sliding scale insulin for diabetic residents. The facility's administration did not file a report or implement the abuse and neglect policies promptly, and there was a lack of thorough investigation and follow-up on the incident.
Failure in Insulin Management and Communication
Penalty
Summary
The facility failed to utilize the Quality Assessment and Performance Improvement (QAPI) process effectively, leading to a significant deficiency in the care of a resident with type 1 diabetes. On the morning of October 6, 2024, the resident had a critically high blood sugar level of 552, and the on-call provider was notified. However, the resident refused medications until he received the proper insulin. Staff A, an LPN, did not communicate the new orders for increased insulin and sliding scale coverage to Staff B, the LPN taking over the shift, nor were these orders transcribed into the medical record. Consequently, Staff B did not reassess the resident's blood glucose or follow up with the provider, leading to the resident calling 911 twice and eventually being admitted to the hospital with Diabetic Ketoacidosis. The deficiency was further compounded by a lack of proper documentation and communication between staff members. Staff A failed to document the text message communications with the on-call medical doctor in the resident's medical record. Additionally, there was no documentation of further blood glucose checks after the initial high reading. Staff B, who took over care, was not informed of the specific blood sugar level and did not take steps to reassess or address the resident's condition, despite the resident's complaints and eventual call to emergency services. Interviews with facility staff revealed a breakdown in following professional standards of practice and facility policies. The Director of Nursing acknowledged that the situation should have been avoided and considered it neglect. The facility did not conduct a thorough investigation or implement the abuse and neglect policies promptly. The administrator and other staff members admitted to not fully understanding the severity of the situation until after the resident's daughter raised concerns, highlighting a systemic failure in communication and adherence to established procedures.
Removal Plan
- The Executive Director received education from the Regional President on the CMS Five Elements of Quality Assurance Performance Improvement (QA/PI) and reviewed the findings indicating facility failed to identify areas not in compliance regarding the nurse failing to reassess the resident, failed to document the change-in-condition, lack of shift-to-shift report, insulin administration, Abuse and Neglect identification and process, failed to follow policies and procedures when transferring resident to the hospital, and lack of communication between staff and providers.
- The Executive Director was educated on the Quality Assurance Performance Improvement (QA/PI) process to include education on identifying a problem, starting and completing an investigation, and implementing a Performance Improvement Plan (PIP) and Plan of Correction (POC).
- The Executive Director was educated on the reporting process of a potential deficient practice to the Quality Assurance Performance Improvement (QA/PI) by notifying the Executive Director and/or Director of Nursing.
- Key staff (including the Medical Director, Director of Nursing, Infection preventionist, Wound Care Nurse, Activities Director, Medical Records, Human Resources, Business Office Managers, and the Environmental Services Manager) were educated on the CMS Five Elements of Quality Assurance Performance Improvement (QA/PI) and reviewed the findings indicating facility failed to identify areas not in compliance regarding the nurse failing to reassess the resident, failed to document the change-in-condition, lack of shift-to-shift report, insulin administration, Abuse and Neglect identification and process, failed to follow policies and procedures when transferring resident to the hospital, and lack of communication between staff and providers.
- Key staff were educated on the Quality Assurance Performance Improvement (QA/PI) process to include education on identifying a problem, starting and completing an investigation, and implementing a Performance Improvement Plan (PIP) and Plan of Correction (POC).
- An Ad Hoc that involved the Executive Director, Medical Director, Director of Nursing identified the root cause analysis was the facility failed to initiate/implement the abuse/neglect policy including a complete investigation.
Failure to Implement Policies Leads to Resident Neglect
Penalty
Summary
The facility failed to implement its policies and procedures to prevent abuse and neglect, specifically in the case of a resident with multiple complex medical conditions, including Type 1 Diabetes Mellitus. The resident was admitted with a regimen that included insulin management, but there was a failure to administer the correct insulin as per the resident's needs. On a particular day, the resident's blood sugar was recorded at a dangerously high level of 552, and the resident refused medication, stating he was not receiving the proper insulin. Despite this, the staff did not take appropriate action to address the resident's refusal or the high blood sugar level. The LPN on duty communicated with the on-call medical doctor via personal text messages, but the orders received were not transcribed into the electronic medical record. The resident's blood sugar was not rechecked after the initial high reading, and the resident eventually called 911, leading to his transfer to the hospital where he was diagnosed with diabetic ketoacidosis. The facility's Director of Nursing and Administrator acknowledged that the situation was not handled according to professional standards, and the neglect was not reported or investigated as required by the facility's policies. Interviews with staff revealed a lack of communication and documentation regarding the resident's condition and the orders received. The staff involved were not suspended during the investigation, and there was no disciplinary action taken. The facility's policies on abuse and neglect were not followed, and a root cause analysis was not conducted promptly. The failure to adhere to established procedures and the lack of a thorough investigation contributed to the neglect of the resident's medical needs.
Breach of Resident Information Confidentiality
Penalty
Summary
The facility failed to safeguard medical record information against unauthorized use, maintain complete and accurate medical records, and ensure the confidentiality of the medical record for a resident. The resident, who had multiple medical conditions including diabetes mellitus type 1 and chronic kidney disease, refused all medications until receiving the proper insulin. Despite the resident's refusal, the staff did not document the physician's orders in the electronic medical record, nor did they record the text message communications regarding the physician notification or orders. The staff used personal cell phones to communicate with the on-call medical doctor about the resident's condition and medication refusal. This communication included the resident's full name and medical information, which was shared via unsecured text messages. The facility's policy prohibits the use of personal electronic devices for sharing protected health information (PHI), yet staff members routinely used their personal phones for such communications, citing convenience and the lack of a company-issued device. Interviews with various staff members, including the Administrator and Director of Nursing, revealed a lack of adherence to the facility's policy on cell phone use and the handling of PHI. The staff admitted to using personal devices to text medical information, often deleting messages after receiving orders. The facility's policy clearly states that PHI should never be stored or shared on personal devices, highlighting a significant breach in maintaining the confidentiality and security of resident information.
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Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
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