Aviata At St Cloud
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Cloud, Florida.
- Location
- 4641 Old Canoe Creek Road, Saint Cloud, Florida 34769
- CMS Provider Number
- 105888
- Inspections on file
- 29
- Latest survey
- October 10, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Aviata At St Cloud during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment reported being touched inappropriately by another cognitively impaired resident. The incident was reported to two LPNs, but neither ensured immediate safety measures or completed required assessments and documentation. Notification to the DON was delayed, and a full investigation was not initiated until the following day, contrary to facility policy.
The facility did not provide a homelike dining experience for residents during breakfast and dinner in the unit day/dining rooms. Meals were served on trays, creating an institutional appearance, with no centerpieces or table linens. Staff interviews revealed a lack of guidance on creating a homelike environment, and the facility's policy did not address this need.
The facility did not provide a homelike dining experience for residents eating breakfast and dinner in unit dayrooms. Observations showed residents eating from trays without table linens or centerpieces, creating an institutional feel. Staff interviews indicated this was a routine practice, and the facility's meal distribution policy lacked guidance on ensuring a homelike environment.
The facility failed to implement proper hand hygiene protocols for 23 residents before meals, as observed in the dining room. Staff, including CNAs, did not offer wipes or other hygiene measures, despite acknowledging the importance of preventing germ spread. The facility's policy emphasized hand hygiene but did not specify offering it to residents before meals. Interviews revealed a lack of consistent practice and awareness among staff, with the Infection Preventionist expressing disappointment over the situation.
During a survey, it was found that an egress door near a resident room on the 100 Hall did not positively latch, violating NFPA 101 standards. The Director of Maintenance acknowledged the issue, which was documented with photographic evidence.
The facility was cited for a repeat deficiency in reporting abuse allegations, as identified in both a December 2024 survey and the current survey. The Administrator did not review actual grievance forms, only logs, and was unable to confirm actions taken to prevent repeat issues. The facility's policies require review of grievances and abuse allegations during QAPI meetings, but insufficient auditing and oversight were noted.
A resident with cognitive impairment filed a grievance about being yelled at by a CNA, but the facility failed to properly investigate or report the incident. The grievance was not discussed in detail during meetings, and the Administrator was unaware of it until the survey. The facility did not adhere to its grievance policy, which requires prompt resolution and communication with the resident.
The facility failed to prevent further abuse and did not timely report allegations of abuse for two residents. One resident, who was cognitively impaired, filed a grievance about verbal abuse by a CNA, which was not reported or investigated. Another resident, who was cognitively intact, reported a CNA raised her hand as if to hit him. The facility's investigation was inadequate, lacking necessary documentation and timely reporting to the State Agency.
A resident dependent on staff for hygiene reported being yelled at by a CNA after needing to be changed. The grievance was documented but not investigated or reported to the State agency. The Social Services Director and Administrator were unaware of the grievance, and the facility's grievance process was not followed.
Two residents reported incidents of neglect involving CNAs, which were not properly reported or investigated by the facility. One resident was yelled at by a CNA for needing to be changed, and another felt threatened when a CNA allegedly raised her hand as if to hit him. The facility failed to report these incidents to the State Agency and did not conduct a thorough investigation, leading to a deficiency in handling allegations of neglect.
A resident with cognitive impairment and speech difficulties was involved in an altercation with an LPN, who allegedly cursed at him after being punched. The incident was not reported until the end of the shift, despite multiple staff witnessing it. Facility policy requires reporting within two hours, which was not followed, leading to a deficiency in abuse reporting procedures.
A facility failed to update a care plan for a resident with severe cognitive impairment and wandering behaviors. Despite significant changes in the resident's behavior, including disorganized thinking and wandering into other residents' rooms, the care plan was not revised after multiple incidents. The facility's policies required care plans to be updated based on changing needs, which was not followed.
The facility failed to maintain complete and accurate medical records for two residents involved in an alleged abuse incident. One resident attempted to pull another out of bed, and although staff intervened, the documentation of the event and immediate care was incomplete. The Social Service Director and RN did not properly document their observations and actions in the electronic medical record system, contrary to facility policy.
The facility failed to ensure a safe smoking environment for residents, with staff not providing adequate supervision or following smoking policies. Residents, including those with cognitive impairments, were observed smoking unsupervised, retaining lighters, and using overflowing ashtrays. Staff were either inside the building or unaware of the facility's smoking policies, leading to unsafe practices.
Two residents experienced deficiencies in IV care at the facility. One resident had a midline IV catheter without a documented dressing change, contrary to facility policy. Another resident with a PICC line had an overdue dressing change, and the green cap on the IV tubing was not replaced. The DON confirmed the lack of adherence to standards for catheter care and the need for staff to follow proper procedures.
The facility failed to administer oxygen therapy as ordered for two residents. One resident received oxygen without a physician's order, and another received a higher flow rate than prescribed. The discrepancies were confirmed by nursing staff, and adjustments were made to comply with physician orders.
A resident with multiple health conditions was found in a lethargic state with suspected illicit drugs. The weekend supervisor nurse confiscated the item but failed to log the incident or initiate an investigation. The facility's policies for incident investigation were not followed, and the suspected drug was improperly disposed of without documentation or a second witness.
A resident with multiple health issues, including diabetes and heart failure, was found with suspected illicit drugs and later admitted to cocaine use. Despite being on Alprazolam and Morphine, the facility did not update the care plan to address potential drug interactions. The staff was unaware of the drug use until a survey, and the Weekend Supervisor lacked training on handling such incidents.
A resident with multiple health issues developed a pressure ulcer that was not present upon admission to an LTC facility. The facility failed to provide timely treatment, resulting in the wound worsening and leading to severe infections and sepsis. The resident required hospitalization and later died on hospice services. The facility's investigation into the neglect was inadequate, with limited staff interviews and poor documentation of care.
A resident with multiple health issues developed a pressure ulcer that was not treated for 10 days, leading to severe infections and sepsis. The facility failed to implement timely interventions and ensure adequate care, resulting in the resident's hospitalization and death. The resident required significant assistance and was at risk for pressure injuries, but the facility did not initiate a care plan for the wound or accurately assess the risk level. Interviews and records revealed inadequate repositioning and catheter care, contributing to the wound's deterioration.
The facility failed to provide dignified meal assistance to residents, as CNAs were observed feeding residents while standing, contrary to policy requiring them to sit at eye level. This was noted with several residents who had cognitive impairments and required assistance with eating. CNAs acknowledged their actions, citing reasons such as difficulty reaching residents comfortably. The facility's policy emphasizes a pleasant meal experience, which was not followed.
The facility failed to maintain accurate ADL documentation for three residents, leading to deficiencies in medical records. A resident with multiple sclerosis and aphasia had inconsistent documentation of eating and meal consumption. Another resident with intact cognition but requiring assistance had inadequate documentation for dressing and meal consumption. A third resident with Alzheimer's and Parkinsonism had missing ADL documentation for an entire shift. CNAs faced challenges with paper documentation, leading to incomplete records, and the facility's management confirmed the inaccuracies.
A facility failed to update care plans for two residents, leading to deficiencies in care. One resident's pressure ulcer progressed from stage II to stage IV without care plan revisions, while another resident's family preferences were not documented, despite being communicated. The facility's policy required individualized and updated care plans, but these were not adequately revised, resulting in unmet care needs.
A resident with multiple diagnoses, including dyskinesia and Alzheimer's, was admitted with a high fall risk. Despite a care plan that included fall prevention measures like fall mats, these were not implemented due to a lack of communication and verification in the facility's system. The resident experienced two falls without injury, highlighting the failure to ensure proper fall interventions were in place.
The facility failed to maintain safe food temperatures during a dinner meal service. The cook did not take food temperatures before serving, and the parmesan baked zucchini liquid was recorded at 109°F, below the safe threshold. Hamburgers were also served at an unsafe temperature of 98°F, as they were not placed in a steam table well. The Interim CDM and Administrator acknowledged these deficiencies.
A resident was observed in a day room wearing a hospital gown that exposed their hip, compromising their dignity. The resident expressed a preference for different clothing and had limited options in their room. The DON and Administrator acknowledged the issue, noting the availability of clothes from the laundry department, yet the resident was seen in the same state the following day.
Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure timely reporting and thorough investigation of an allegation of sexual abuse involving a cognitively impaired male resident and a female resident with moderate cognitive impairment. The incident occurred when the female resident was awakened in her room by the male resident touching her back, arm, and stomach. She screamed, causing the male resident to leave, and subsequently reported the incident to another resident, who then informed an LPN. The LPN and another nurse were made aware of the allegation, but neither took immediate steps to ensure the safety of the resident or to prevent the alleged perpetrator from accessing other residents. Despite being informed of the incident, the assigned nurse did not perform a skin check on the alleged victim, did not complete an incident report, and only attempted to notify the DON via text message, which was not received until the following morning. The nurse did not escalate the report to the Administrator or follow up when the initial notification failed. The DON and Administrator delayed gathering statements from staff and did not initiate a full investigation, as they believed the event did not rise to the level of harm. The male resident continued to wander the hallways without supervision until the victim's sister insisted on further action. The facility's policies required immediate segregation of the alleged perpetrator, a thorough nursing evaluation, notification of the attending physician, and completion of an incident report upon any allegation of abuse. These procedures were not followed, as the staff failed to promptly report the incident to appropriate authorities, did not conduct required assessments, and did not initiate a comprehensive investigation. The lack of immediate and thorough response resulted in a delay in implementing corrective actions to protect residents.
Lack of Homelike Dining Experience in Unit Day/Dining Rooms
Penalty
Summary
The facility failed to provide a homelike dining experience for residents during breakfast and dinner meals in the day/dining rooms on both nursing units. Observations revealed that meals were served on trays with dishes, drinks, and flatware left on the trays, creating an institutional appearance. There were no centerpieces or table linens on the tables, and residents expressed that the environment felt crowded and less homelike. The facility's main dining room was not open for breakfast or dinner, leaving residents to eat in the unit day/dining rooms or their bedrooms. Interviews with staff, including the Activities Director and Certified Nursing Assistants, indicated a lack of awareness and guidance regarding the removal of meal trays to create a more homelike environment. The facility's policy on meal distribution did not address the need for a homelike dining experience. The Administrator and Regional Vice President of Operations acknowledged the issue and mentioned plans to improve the dining environment, but these actions were not part of the deficiency findings.
Plan Of Correction
1. Ensured trays and lids were removed from the tables during all meals in the day room areas, tablecloths and centerpieces were ordered on. The dining room was opened on for dinner, then scheduled to open the following day for breakfast. 2. Observed all dining areas and corrected all issues found at that time. Daily observation of the day room areas and dining room to ensure that resident meals are served in a homelike environment with tablecloths and centerpieces, as well as the trays being removed under the plate and lids removed from table. 3. Educate all staff on removing trays and lids from table for all meals with an emphasis on meals served in day rooms. Audit of two meals per day to ensure that meals are set properly on table in the dining room and day rooms, without lids on tables, tablecloths and centerpieces in place including cleanliness. The dining room is now scheduled to be opened for breakfast, lunch, and dinner according to facility policy. 4. 5 Random Quality reviews will be completed weekly, including weekends by weekend supervisor or designee. The audits will include homelike environment, such as plates and lids removed from trays for all meals and main dining room open for all meals. Audit will include observation of tablecloths and centerpieces to ensure compliance. 5. NHA/DON will conduct a quality review on mealtimes being set properly and homelike environment components are in place. This will be conducted 5x weekly for 4 weeks, then weekly for 2 months.
Lack of Homelike Dining Experience in Unit Dayrooms
Penalty
Summary
The facility failed to provide a homelike dining experience for residents eating breakfast and dinner in the day/dining rooms on both nursing units. During observations, residents were seen eating their meals from trays, which created an institutional appearance. The tables lacked centerpieces or linens, and meal trays with lids were left on the tables, contributing to a non-homelike environment. Residents expressed that the dining experience was better during lunch when trays were removed, and dishes were placed directly on the tables, with flower centerpieces enhancing the atmosphere. Staff interviews revealed that the practice of leaving dishes on trays during breakfast and dinner in the unit dayrooms was routine, with no specific reason provided for this method. The facility's policy on meal distribution did not address the need for a homelike dining experience. The Activities Director and other staff acknowledged the importance of creating a homelike environment, but there was no directive to remove trays during these meals, indicating a lack of guidance and awareness in maintaining a homelike setting for residents during all meals.
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. 1. Ensured trays and lids were removed from the tables during all meals in the day room areas, tablecloths and centerpieces were ordered on. The dining room was opened on for dinner, then scheduled to open the following day for breakfast. 2. Observed all dining areas and corrected all issues found at that time. Daily observation of the day room areas and dining room to ensure that resident meals are served in a homelike environment with tablecloths and centerpieces, as well as the trays being removed under the plate and lids removed from table. 3. Educate all staff on removing trays and lids from table for all meals with an emphasis on meals served in day rooms. Audit of two meals per day to ensure that meals are set properly on table in the dining room and day rooms, without lids on tables, tablecloths and centerpieces in place including cleanliness. The dining room is now scheduled to be opened for breakfast, lunch, and dinner according to facility policy. 4. 5 Random Quality reviews will be completed weekly, including weekends by weekend supervisor or designee. The audits will include homelike environment, such as plates and lids removed from trays for all meals and main dining room open for all meals. Audit will include observation of tablecloths and centerpieces to ensure compliance. 5. NHA/DON will conduct a quality review on mealtimes being set properly and homelike environment components are in place. This will be conducted 5x weekly for 4 weeks, then weekly for 2 months.
Failure to Implement Resident Hand Hygiene Before Meals
Penalty
Summary
The facility failed to implement proper hygiene protocols for residents before meals, which is a critical component of their infection prevention and control program. Observations revealed that 23 residents dining in the main dining room were not offered any means to clean their hands before eating. Staff members, including CNAs, confirmed that the practice of providing wipes or other hygiene measures had ceased over time, despite acknowledging the importance of hand hygiene in preventing the spread of germs. The facility's policy on handwashing and hygiene, dated 2019, emphasized the importance of hand hygiene as a primary means to prevent the spread of infections, yet it did not specify that staff should offer hygiene to residents before meals. Interviews with several CNAs indicated a lack of consistent practice and awareness regarding the importance of offering hand hygiene to residents before meals. CNA D mentioned that the practice of handing out wipes had stopped, while CNA C and CNA B acknowledged that they had not been reminded or instructed to offer hygiene measures to residents. The facility's Infection Preventionist expressed disappointment that staff were not aware of the need to offer hand hygiene, despite previous education efforts. The Preventionist noted that resources such as washcloths, wipes, and gel were available for use, but staff had not been utilizing them to ensure residents' hands were clean before meals.
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. 1. On preventionist immediately educated staff on the importance of hygiene for residents before and after meals. On NHA immediately obtained sanitizing wipes and sanitizer, provided them to staff and residents to use at that time and prior to upcoming meals. 2. On NHA observed both units and corrected any issues at that time. Both units were observed, and the deficient practice was corrected immediately. 3. The Director of Nursing/ Preventionist will educate all current nursing and activity staff on proper control practices related to hygiene before and after meals for residents. The Director of Nursing/ Preventionist/ or designee will administer an eating support competency to measure understanding. The Director of Nursing/ Preventionist will educate alert and oriented residents on proper hygiene before and after meals for increased awareness. The Administrator or designee will conduct 5 random quality reviews including weekends by weekend supervisor or designee. The audit will include control practices regarding hygiene for residents before and after meals to ensure compliance. 4. The Administrator or designee will conduct a quality review on proper hygiene prior to meals. This will be conducted 5 times weekly for 4 weeks, then weekly for 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance improvement Committee monthly until committee determines substantial compliance has been met.
Egress Door Latching Deficiency
Penalty
Summary
The facility was found to have a deficiency related to the maintenance of egress doors, as observed during a survey conducted on April 8th. During the facility tour, it was noted that one of the nine egress doors, specifically near resident room 118 on the 100 Hall, failed to positively latch. This issue was identified after testing the door three times, each time resulting in the latching mechanism not engaging properly. The Director of Maintenance was present during the inspection and acknowledged the deficiency. The failure of the door to latch properly is a violation of the National Fire Protection Association (NFPA) 101 standards, which require that doors in a required means of egress must not be equipped with a latch or lock that requires a tool or key from the egress side unless specific conditions are met. The deficiency was documented with photographic evidence. The report does not mention any specific residents affected by this deficiency or any immediate consequences resulting from the door's failure to latch. However, the presence of the Director of Maintenance during the survey and his concurrence with the findings indicate an awareness of the issue at the facility level.
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. 1. The one egress door near resident room 118 on the 100 hall, noted to not positively latch when tested will be repaired to proper function. 2. Additional egress doors will be reviewed for positive latching. 3. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Egress Doors specific to maintaining egress doors to positively latch, and will continue to monitor in accordance with NFPA standards. 4. Any findings will be reported to the monthly QAPI Committee for further review.
Repeat Deficiency in Reporting Abuse Allegations
Penalty
Summary
The facility failed to implement its policies effectively, particularly in monitoring and tracking performance in previously identified areas of concern. During a complaint survey conducted in December 2024, the facility was cited for F609 due to issues related to the reporting of abuse allegations. In the current survey, the same citation was identified again, indicating a lack of sufficient auditing and oversight to address the previous deficiency. The Administrator admitted to not reviewing the actual grievance forms, only the grievance log presented at the monthly Quality Assurance and Performance Improvement (QAPI) meetings. The facility's policies, including the Complaint/Grievance policy and the Abuse, Neglect, Exploitation & Misappropriation policy, require that grievances and allegations of abuse be reviewed during QAPI meetings. However, the Administrator, who was not in position during the December 2024 survey, could not confirm what actions were taken to prevent repeat deficiencies. The facility's Quality Assurance Performance Improvement Program policy emphasizes the importance of focusing on care outcomes and quality of life, yet the failure to adequately monitor and address previous deficiencies suggests a gap in the implementation of these policies.
Plan Of Correction
1) On QAPI was reviewed by the Regional Vice President of Operations and Regional Director of Clinical Services for the months of and audits were reviewed and updated. (2) A comprehensive review of QAPI plans were conducted by the RVPO and RDCS to ensure all actions and supporting audits were completed and ongoing audits up to date. Any areas of concern were corrected at this time. (3) 1. Education provided by RDCS to the Interdisciplinary team on the importance of QAPI and how to ensure efficient outcomes through monitoring and evaluation according to facility QAPI policy; as well as a comprehensive review of the facility's Quality Assurance Performance Improvement program policy. 2. Education provided by the Executive Director to the IDT on how the facility will monitor the effectiveness of the performance improvement plan related to quality assurance and process improvement. 3. All grievances (grievance forms and log) will be reviewed by ED, SSD and DON daily 5 days a week. 4. Quality reviews will be conducted weekly for performance improvement adherence; if indicated, an Adhoc QAPI will be completed and submitted to monthly QAPI with any findings. (4) A quality review will be completed by the Executive Director or designee of grievances to ensure the policy and process is adhered to, along with a quality review of performance improvement audits each 5 times a week for 4 weeks, and then weekly for 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Follow Grievance Process for Resident Complaint
Penalty
Summary
The facility failed to ensure staff were knowledgeable of and followed their grievance process for a resident who filed a concern about being yelled at by a CNA. The resident, who was cognitively impaired and dependent on staff for personal hygiene, reported that the CNA yelled at her for needing to be changed again. The grievance was documented but not properly investigated or followed up with the resident, and it was not reported to the State agency as required. The Social Services Director, who was responsible for overseeing grievances, and the Administrator were not aware of the grievance until it was brought to their attention during the survey. The grievance was not discussed in detail during morning meetings, and the Administrator confirmed that it was not investigated as required. The facility's grievance policy, which mandates prompt efforts to resolve complaints and inform residents of progress, was not adhered to in this case.
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. 1) On , Resident #7 reported grievance was submitted to AIRS system by NHA. (2) A comprehensive review of all grievances for the months of and was conducted by Regional Vice President of Operations, Executive Director and Social Services Director to ensure adherence to facility policy. No new issues found. (3) 1. Education provided by RVPO to SSD and ED on grievance and reporting process. 2. Education provided to all staff on the grievance and reporting process, postings and placement of grievance forms. 3. All grievances are reviewed by ED, SSD and DON daily; supervisor calls and reviews grievances with ED, SSD, DON or designee on weekends. 4. Grievance policy reviewed by Executive Director in resident council meeting on. 5. A quality review is conducted weekly by ED/DON or SSD on grievances and reportable incidents. (4) A quality review will be completed by the Executive Director/designee of grievances and reportable incidents, to ensure the policy/process is adhered to, 5 times a week for 4 weeks, and then weekly for 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to prevent further abuse and did not timely and accurately report allegations of abuse to the State Agency for two residents. Resident #7, who was cognitively impaired and dependent on staff for personal hygiene, filed a grievance about being verbally abused by a CNA. The grievance was not reported to the State Agency, and the facility's Administrator was unaware of the grievance until it was brought to her attention during the survey. The grievance was not investigated as required, and the incident was not included in the facility's Reportable Event Log. Resident #1, who was cognitively intact but required assistance for personal hygiene, reported an incident where a CNA allegedly raised her hand as if to hit him. The incident was reported to the facility's Director of Nursing (DON) and the Weekend Supervisor, but the investigation was inadequate. The facility did not collect witness statements from all involved staff, and the DON did not follow up on the investigation. The facility's report to the State Agency was delayed, and the investigation folder lacked necessary documentation, such as witness statements and progress notes. The facility's policy on abuse, neglect, and exploitation was not followed. The policy required immediate segregation of the suspect from residents, a thorough nursing evaluation, and timely reporting to the State Agency. However, the facility did not perform a head-to-toe assessment on Resident #1, and the investigation was not conducted thoroughly. The facility also failed to provide emotional support and counseling to the residents involved, as outlined in their policy.
Plan Of Correction
1) On Resident #7 reported grievance was submitted to AIRS system by Executive Director (ED). On Resident #1 reported was submitted to AIRS system by the Executive Director (ED). (2) A comprehensive review of all grievances for the months of and was conducted by Regional Vice President of Operations, Executive Director and Social Services Director to ensure adherence to facility policy. An audit was conducted on all residents with a of 11 or higher for potential reportable events. No new issues found. (3) 1. Education provided by RVPO to SSD and ED on grievance and reporting process. 2. Education provided to all staff in regards to the grievance and reporting process, postings and placement of grievance forms, reporting events timely to meet 2 hour post allegation window, and 24 hours for events that do not involve or serious bodily injury. 3. All grievances are reviewed by ED, SSD and DON daily, supervisor calls and reviews grievances with ED, SSD, DON or designee on weekends. 4. All investigations will be reviewed by RVPO and RDCS for thoroughness, accuracy and timeliness. 5. A quality review is conducted weekly by ED, DON, and SSD on grievances and reportable incidents. (4) A quality review will be completed by the Executive Director or designee of grievances and reportable incidents to ensure a thorough investigation was completed and to ensure the policy and process is adhered to, 5 times a week for 4 weeks, and then weekly for 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Follow Grievance Process for Resident Complaint
Penalty
Summary
The facility failed to ensure that staff were knowledgeable of and followed their grievance process for a resident who had filed a complaint. The resident, who was dependent on staff for toileting hygiene and required substantial assistance for personal hygiene, reported being yelled at by a CNA after needing to be changed for the second time. The grievance was documented in the Resident Grievance Log, but the investigation findings section was left blank, and there was no follow-up or report submitted to the State agency. The Social Services Director, who was responsible for overseeing grievances, stated that grievances were discussed daily during morning meetings, but the Administrator confirmed that the specific grievance was not brought to her attention. The grievance form was handed to the Social Services Director by the Unit Manager, but it was not read or investigated as required. The facility's policy intended to support residents' rights to voice complaints and resolve them promptly, but in this case, the grievance process was not properly followed, and the grievance was not addressed or reported as necessary.
Plan Of Correction
Grievance was submitted to AIRS system by NHA. A comprehensive review of all grievances for the months of [insert months] was conducted by the Regional Vice President of Operations, Executive Director, and Social Services Director to ensure adherence to facility policy. No new issues found. 1. Education provided by RVPO to SSD and ED on grievance and reporting process. 2. Education provided to all staff on the grievance and reporting process, postings, and placement of grievance forms. 3. All grievances are reviewed by ED, SSD, and DON daily; supervisor calls and reviews grievances with ED, SSD, DON, or designee on weekends. 4. Grievance policy reviewed by Executive Director in resident council meeting on [insert date]. 5. A quality review is conducted weekly by ED/DON or SSD on grievances and reportable incidents. A quality review will be completed by the Executive Director/designee of grievances and reportable incidents to ensure the policy/process is adhered to, 5 times a week for 4 weeks, and then weekly for 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Report and Investigate Allegations of Neglect
Penalty
Summary
The facility failed to prevent and timely report allegations of neglect for two residents. Resident #7, who was dependent on staff for toileting hygiene and needed substantial assistance for personal hygiene, filed a grievance after a CNA yelled at her for needing to be changed. The grievance was not reported to the State Agency, and the Administrator was unaware of it until it was brought to her attention during the survey. The grievance was not investigated as required, and the Social Service Director and Unit Manager were also unaware of the complaint. Resident #1, who had a history of right lower extremity issues and required substantial assistance for hygiene, reported an incident where a CNA allegedly raised her hand as if to hit him. The resident felt threatened and used foul language in response. The incident was reported to the Weekend Supervisor and the DON, but no immediate investigation or skin check was conducted. The DON later determined it was a customer service issue and did not report it as an abuse allegation. Witness statements were not collected from staff present during the incident, and the facility's investigation was incomplete. The facility's policy required immediate reporting of abuse or neglect allegations, segregation of the suspect from residents, and a thorough investigation. However, these procedures were not followed in the cases of residents #1 and #7. The facility failed to document and report the incidents to the State Agency within the required timeframe, and the investigation process was not adequately conducted, leading to a deficiency in handling allegations of neglect.
Plan Of Correction
1) On Resident #7 reported grievance was submitted to AIRS system by NHA. (2) A comprehensive review of all grievances for the months of and was conducted by Regional Vice President of Operations, Executive Director and Social Services Director to ensure adherence to facility policy. No new issues found. (3) 1. Education provided by RVPO to SSD and ED on grievance and reporting process. 2. Education provided to all staff on the grievance and reporting process, postings and placement of grievance forms. 3. All grievances are reviewed by ED, SSD and DON daily; supervisor calls and reviews grievances with ED, SSD, DON or designee on weekends. 4. Grievance policy reviewed by Executive Director in resident council meeting on. 5. A quality review is conducted weekly by ED/DON or SSD on grievances and reportable incidents. (4) A quality review will be completed by the Executive Director/designee of grievances and reportable incidents, to ensure the policy/process is adhered to, 5 times a week for 4 weeks, and then weekly for 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Timely Report Alleged Verbal Abuse Incident
Penalty
Summary
The facility failed to ensure timely reporting of an alleged verbal abuse incident involving a resident with moderate cognitive impairment and speech impediment. The resident, who had a history of cerebral infarction, anxiety disorder, and depression, was involved in an altercation with an LPN. The LPN was heard yelling at the resident and allegedly cursed at him after he punched her in the abdomen. Despite the incident occurring around 10:00 PM, it was not reported until the end of the shift, over nine hours later. Multiple staff members, including CNAs and an RN, witnessed or were aware of the incident but did not report it immediately, assuming it was the LPN's responsibility. The facility's policy requires that any allegations of abuse be reported within two hours, but this protocol was not followed. The LPN admitted to cursing at the resident and acknowledged that she should have reported the incident immediately, as per her training. The Director of Nursing and other administrative staff were only informed of the incident the following morning. The facility's policy on abuse, neglect, and exploitation mandates immediate reporting of any witnessed or known incidents, which was not adhered to in this case. The failure to report the incident promptly constitutes a deficiency in the facility's adherence to its own policies and procedures regarding abuse reporting.
Failure to Update Care Plan for Resident with Wandering Behaviors
Penalty
Summary
The facility failed to develop, implement, and revise a person-centered comprehensive care plan for a resident with severe cognitive impairment and wandering behaviors. The resident, who was admitted with diagnoses including a wedge compression fracture, Parkinson's Disease, and cognitive communication deficit, exhibited significant changes in behavior during their stay. Initially, the resident did not show any physical or verbal behaviors towards others, but by the time of discharge, they displayed disorganized thinking, wandering behaviors, and other actions such as pacing, rummaging, and disrobing in public. Despite these changes, the care plan was not adequately updated to address the resident's evolving needs. The facility's records revealed that the resident had an electronic wander bracelet ordered after the first incident of wandering into another resident's room. However, after subsequent incidents, including an alleged resident-to-resident abuse where the resident attempted to pull another resident out of bed, the care plan interventions were not revised. The MDS Coordinator and the DON acknowledged that the care plan was not updated after the second and third incidents, despite the expectation for the Interdisciplinary Team to discuss and determine the effectiveness of care plan interventions. The facility's policies required that care plans be reviewed and updated based on the resident's changing needs, which was not adhered to in this case.
Incomplete Documentation of Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents involved in a reportable incident of alleged resident-to-resident abuse. The incident occurred when one resident entered another resident's room and attempted to pull her out of bed. Although staff intervened and assessed the residents, the documentation of the event and the immediate care provided was incomplete. Specifically, there was no documentation in the medical records detailing the incident, the assessments conducted, or the notifications made to family and physicians. The Social Service Director and Registered Nurse involved in the incident did not document their observations and actions in the electronic medical record system. The SSD delayed documenting in the system and instead used a typed note on plain paper, while the RN failed to record the assessment of the resident's condition. The Director of Nursing confirmed that the expected protocol was not followed, as staff were required to document any changes in resident condition and incidents before the end of their shift. The facility's policies emphasized the importance of maintaining accurate clinical records to ensure effective communication among healthcare professionals, which was not adhered to in this case.
Unsafe Smoking Practices in LTC Facility
Penalty
Summary
The facility failed to ensure a safe smoking environment for residents, as observed during a survey. Ten residents were reviewed for smoking, and all were found to be in an unsafe smoking environment. Residents were observed smoking on the patio without staff supervision, and some residents, including those with cognitive impairments, were allowed to keep their own lighters and cigarettes. The staff responsible for supervising the smoking activity were either inside the building or unaware of the facility's smoking policies, leading to residents lighting each other's cigarettes and using overflowing ashtrays. Specific residents, such as one with bilateral leg amputations and another who was blind, were observed with lighters and cigarettes in their possession, contrary to the facility's policy. The blind resident required assistance to light her cigarette, which was provided by another resident instead of staff. Additionally, residents with cognitive impairments were not adequately supervised, and their smoking materials were not retrieved by staff after smoking sessions, as required by their care plans. The facility's policies and procedures for supervised smoking were not followed, as staff did not provide direct supervision or ensure the safe handling of smoking materials. The Director of Nursing and Nursing Home Administrator acknowledged the lapses in supervision and policy enforcement, but staff continued to allow residents to smoke unsupervised and retain their lighters. The facility's failure to adhere to its smoking policies and provide adequate supervision posed a risk to resident safety.
Deficiencies in IV Care and Maintenance
Penalty
Summary
The facility failed to provide appropriate intravenous (IV) care and services for two residents, leading to deficiencies in the administration and maintenance of IV therapy. Resident #2 was observed with a midline IV catheter in her right upper arm without a date on the dressing, indicating a lack of adherence to the facility's policy for catheter dressing changes. The resident's medical record showed that the IV catheter was placed on 9/09/24, but there was no documentation of dressing changes within the required 24 hours after insertion or every 5-7 days thereafter. The Director of Nursing (DON) confirmed the absence of documentation and noted that the last dose of IV medication was administered on 9/11/24, seven days prior to the observation. Resident #18, who was readmitted from an acute care hospital with a peripherally inserted central catheter (PICC) line, also experienced deficiencies in IV care. The dressing on his PICC line was dated 9/06/24 and had not been changed by the facility staff, despite being overdue for a change by 9/13/24. The resident expressed concerns about the lack of dressing changes and the green cap on the IV tubing not being replaced. The assigned Registered Nurse (RN) admitted to not changing the dressing due to it not being on her schedule, although she acknowledged it should have been changed every 7 days and as needed. The facility's policy for catheter insertion and care required central venous catheter dressings to be changed at specific intervals to prevent infections. The DON acknowledged that the nurses were expected to follow these standards and that any nurse administering IV medications should have noticed and addressed the outdated dressing. The DON also mentioned the need to verify the frequency of changing the green cap on the IV tubing, which was not being done as required.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to obtain a physician's order for oxygen therapy and did not administer oxygen therapy as ordered for two residents. Resident #2 was observed with a nasal cannula connected to an oxygen tank at a flow rate of 3 liters per minute, but there was no physician's order for this oxygen use. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed the absence of a physician's order in the resident's medical record. Additionally, the oxygen tank was found to be empty, and the DON acknowledged that an order might have been mistakenly omitted when the resident was readmitted from the hospital. Resident #13 was observed receiving oxygen at 4 liters per minute via nasal cannula, although the physician's order specified a flow rate of 2 liters per minute. The resident's care plan included instructions to administer oxygen per physician orders, and there was no indication that the resident adjusted her own oxygen settings. The assigned LPN confirmed the discrepancy and adjusted the oxygen concentrator to the correct flow rate. The DON stated that nurses should verify oxygen settings during each room visit to ensure compliance with physician orders.
Failure to Investigate Suspected Drug Possession
Penalty
Summary
The facility failed to investigate an incident involving a resident who was found with suspected illicit drugs. The resident, a male with multiple health conditions including diabetes, heart failure, and nicotine dependence, was discovered by a weekend supervisor nurse in a lethargic state on the patio. A small plastic bag containing a suspected illicit drug was found in the resident's cigarette pack. The nurse confiscated the item and informed the physician, who advised holding the resident's narcotics and monitoring his vital signs. However, the incident was not logged, and no investigation was initiated. The facility's policies and procedures for incident investigation were not followed. The weekend supervisor did not report the incident to the on-call supervisor or initiate an incident report. The suspected drug was disposed of by flushing it down the toilet without proper documentation or a second witness. The Director of Nursing and Unit Manager were unaware of the incident until much later, and the facility's incident log showed no record of the event. The weekend supervisor admitted to not receiving training on handling suspected illicit drugs, contributing to the mishandling of the situation.
Failure to Update Care Plan for Drug Interaction Risk
Penalty
Summary
The facility failed to update an individualized care plan for a resident who was at risk for adverse drug interactions due to the use of opioid and antianxiety medications. The resident, a male with multiple diagnoses including diabetes, heart failure, and phantom limb pain syndrome, was found by a nurse in a lethargic state with suspected illicit drugs. Despite the incident and a subsequent report by an APRN documenting the resident's cocaine use, the care plan was not revised to address potential drug interactions with the resident's prescribed medications, Alprazolam and Morphine. The facility's staff, including the Nursing Home Administrator and Director of Nursing, were unaware of the resident's illicit drug use until the survey. The Weekend Supervisor, who discovered the resident with suspected drugs, had not received training on handling such situations and did not initiate an incident report. The facility's policy required the care plan to be updated based on changing needs, but this was not done, leaving the resident without a plan to manage potential adverse interactions between prescribed and illicit drugs.
Neglect in Pressure Injury Care Leads to Resident Harm
Penalty
Summary
The facility neglected to provide appropriate care and services to prevent a pressure injury for a vulnerable and physically impaired resident. The resident, an elderly male with multiple diagnoses including Alzheimer's disease and type 2 diabetes, was admitted with intact skin but later developed a pressure ulcer that was not present upon admission. The resident required moderate to maximum assistance with activities of daily living and was always incontinent of bowel movements. Despite these needs, the facility failed to implement preventative interventions and ensure timely and adequate treatments for the pressure injury. The resident's pressure ulcer was identified by a CNA, but treatment was delayed for 10 days, during which time the wound worsened. The medical record showed that almost half of the wound treatments were not documented as completed. The resident's condition deteriorated, leading to severe wound infections and sepsis, which required hospitalization. The facility's failure to act promptly and effectively resulted in actual harm to the resident, who later died while on hospice services. The facility also failed to conduct a thorough investigation into the neglect after the pressure injury worsened. The investigation was limited, with only the wound nurse and Director of Rehabilitation interviewed, and did not include the assigned nurses or CNAs who provided care to the resident. The facility's documentation and follow-up on the resident's care were inadequate, contributing to the neglect and subsequent harm experienced by the resident.
Removal Plan
- Educate nurses on wound care and documentation expectations.
- Educate the Interdisciplinary Team (IDT) and Unit Managers.
- Conduct random audits.
- Initiate a Performance Improvement Plan (PIP) regarding pressure wounds.
- Provide additional education for CNAs on skin assessment and notification procedures.
- Conduct facility-wide audit to ensure all residents have up-to-date skin assessments and wound dressing changes.
- Revise PIP to include review of physician orders for treatment, care plan review, physical checks of residents, and documentation support.
Failure to Prevent and Treat Pressure Ulcer Leads to Resident's Death
Penalty
Summary
The facility failed to provide adequate care and services to prevent the development and worsening of pressure injuries for a resident, resulting in actual harm. The resident, an elderly male with multiple diagnoses including Alzheimer's disease and diabetes, was admitted with intact skin but developed a pressure ulcer that was not treated for 10 days after it was identified. This delay in treatment led to the wound worsening, resulting in severe infections and sepsis, ultimately requiring hospitalization and leading to the resident's death on hospice care. The medical record review revealed that the resident required significant assistance with activities of daily living and was incontinent, which increased his risk for pressure injuries. Despite this, the facility did not implement timely preventative interventions or ensure adequate care for the pressure injury. The resident's care plans included goals to prevent skin breakdown and maintain skin integrity, but there was no care plan initiated for the actual pressure wound. The Braden Score assessments inaccurately reflected the resident's risk level, and there was a lack of documentation and follow-up on the pressure wound by the nursing staff. Interviews with staff and family members highlighted the facility's failure to reposition the resident regularly and change his urinary catheter as required. The wound care nurse confirmed that the resident's wound was not discussed in clinical meetings, and there were missing orders in the medical record. The wound physician's notes indicated a significant deterioration of the wound, and the facility's practice of having floor nurses perform wound care instead of the wound nurse contributed to the inadequate treatment. The facility's lack of timely and appropriate interventions led to the resident's severe sepsis and subsequent death.
Failure to Ensure Dignified Meal Assistance for Residents
Penalty
Summary
The facility failed to treat residents requiring assistance with meals in a dignified and respectful manner. Observations revealed that Certified Nursing Assistants (CNAs) were feeding residents while standing, which is against the facility's policy that requires CNAs to sit at eye level with residents during meals. This practice was observed with four residents who had varying degrees of cognitive impairment and required substantial assistance with eating. For instance, one resident with multiple sclerosis and aphasia was fed by a CNA who stood next to her bed, while another resident with Parkinson's disease and diabetes was also fed by a standing CNA. The CNAs involved acknowledged their actions, with one stating that she stood because she was unable to reach the resident comfortably due to her height, and another admitting to standing despite knowing the expectation to sit. The facility's policy emphasizes the importance of making the meal experience pleasant and giving residents complete attention, which was not adhered to in these instances. The Director of Nursing and the Regional Nurse Consultant confirmed that CNAs were expected to sit while feeding residents and that the term 'feeders' should not be used to refer to residents.
Inaccurate ADL Documentation for Residents
Penalty
Summary
The facility failed to maintain accurate medical records for activities of daily living (ADLs) for three residents, leading to deficiencies in documentation. Resident #4, with multiple sclerosis and aphasia, had severely impaired cognition and was totally dependent on staff for ADLs. However, her CNA-ADL Tracking Form showed inconsistent documentation of eating and meal consumption percentages for May and June 2024. Similarly, Resident #14, who had intact cognition but required assistance with lower body dressing and toileting, had inadequate documentation for dressing, personal hygiene, and meal consumption in May 2024. Resident #17, with Alzheimer's disease and Parkinsonism, also had severely impaired cognition and was totally dependent on staff, yet her ADL documentation was missing for the entire 7 AM to 3 PM shift in May 2024, with incomplete meal consumption records for both May and June 2024. Interviews with CNAs revealed challenges in documenting ADLs due to the lack of tablets and the cumbersome paper documentation process, which involved 16 pages per resident. CNAs expressed difficulties with the small font size on the forms, leading to incomplete documentation. The North Wing Unit Manager was unaware of the documentation issues, and the Director of Nursing and Administrator confirmed the inaccuracies in the medical records. Despite previous education efforts, the facility's Regional Nurse Consultant acknowledged the need for diligent micromanagement to address the documentation deficiencies.
Deficiencies in Care Plan Updates for Residents
Penalty
Summary
The facility failed to review or revise the individualized pressure ulcer care plan for a resident who developed a pressure ulcer that progressed from stage II to stage IV over 27 days. The resident, a male with multiple diagnoses including Alzheimer's disease and type 2 diabetes, was admitted with intact skin but was discharged with a stage IV pressure ulcer. The care plan was not updated to reflect the actual pressure injury or to include new interventions, despite the resident's condition worsening. The MDS Coordinator acknowledged that the new wound should have triggered a change in the care plan, but no such update was made. Another resident, a female with multiple sclerosis and aphasia, had a care plan that did not address her personal choices and individual needs as communicated by her family. The resident's family had specific preferences for her care, such as using bottled water and specific positioning, which were not included in the care plan. Despite the family providing detailed instructions and attending care conferences, these preferences were not documented in the care plan, leading to inconsistencies in care delivery. The facility's policy required that care plans be individualized and updated based on changing resident needs and preferences. However, the care plans for both residents were not adequately revised to reflect their current conditions and preferences, resulting in deficiencies in meeting their care needs. The interdisciplinary team failed to ensure that the care plans were oriented toward maintaining the residents' highest practicable well-being.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall interventions for a resident who was admitted with a high risk of falls due to multiple diagnoses, including drug-induced subacute dyskinesia, Alzheimer's disease, and Parkinson's disease. Upon admission, the resident was identified as a fall risk, having fallen within the last 30 days, and the family also noted the risk. The care plan included interventions such as keeping the bed in the lowest position and using bilateral fall mats, but these were not effectively implemented. The resident experienced a fall on the day of admission and another fall later, both without injury. The investigation revealed that the fall mats, which were part of the care plan, were not ordered or listed in the CNA care plan/Kardex. The Director of Nursing confirmed that the interventions were not uploaded to the CNA Kardex, and there was no verification process to ensure the care plan interventions were correctly communicated to the CNAs. This oversight contributed to the resident's second fall, as the necessary fall prevention measures were not in place.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to serve food at proper safe temperatures during a dinner meal service. On the specified date, the cook began serving dinner without taking the temperature of the food before service. The first dinner cart was dispatched from the kitchen at 5:30 pm, but the temperatures of the food on the serving line were only taken at 6:02 pm, after the meal service had concluded. The temperature of the parmesan baked zucchini liquid was recorded at 109 degrees Fahrenheit, which was below the safe temperature threshold. The Interim Certified Dietary Manager (CDM) confirmed that the temperature was too low and should have been above 135 degrees Fahrenheit to prevent foodborne illnesses. Additionally, the hamburgers served during the meal were not maintained at a safe temperature. They were placed on a flat half tray across the top of the steam table, rather than in a well, and their temperature was recorded at 98 degrees Fahrenheit at 6:09 pm. The Interim CDM noted that the hamburgers should have been kept in beef broth in a pan to maintain warmth, and all food should be heated to 165 degrees Fahrenheit before leaving the kitchen. The Administrator also acknowledged that the hamburgers should have been placed inside a well on the steam table to achieve a safe temperature.
Resident Dignity Compromised Due to Inadequate Clothing
Penalty
Summary
The facility failed to promote dignity for a resident by not ensuring they were appropriately dressed in a common area. On May 15, 2024, the resident was observed in the day room wearing a yellow hospital gown that exposed their left hip, making them visible to staff and visitors. The resident expressed dissatisfaction with wearing a hospital gown and mentioned having limited clothing in their room, preferring short-sleeved shirts and pants. The Director of Nursing acknowledged the resident's exposure and suggested that if the resident lacked clothing, they could obtain some from the laundry department. An observation of the resident's closet revealed only a sweatshirt and pants. The following day, the Administrator confirmed the expectation that residents should be covered in common areas and noted the availability of donated clothes, yet the resident was again seen wearing a hospital gown.
Latest citations in Florida
Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
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