Birchwood Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sarasota, Florida.
- Location
- 3250 12th St, Sarasota, Florida 34237
- CMS Provider Number
- 105389
- Inspections on file
- 25
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Birchwood Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to ensure sufficient nursing staff and accessible, functional call lights for dependent residents. Several residents reported waiting from 30 minutes to hours for call bell responses, sometimes having to go to the nurses’ station themselves or, in one case, calling 911 when no call bell was available. During observation, multiple residents in bed had call lights on the floor and out of reach, and one room’s call system did not activate until an RN adjusted the wall connection. LPNs reported caring for 20–38 residents per shift, described triaging call lights due to workload, and stated they could not consistently meet expected response times. Grievance logs documented repeated, non-specific “call bell issues” over multiple review periods, and the Activities Director confirmed that residents continued to voice ongoing problems with delayed call light response during resident council meetings.
Surveyors found that multiple residents had unsecured medications left at bedside, including melatonin gummies, eye vitamins, nasal decongestant spray, antacid tablets, arthritis powder, and vaporizing rub stored on nightstands and overbed tables. Nursing staff, the ADON, and the DON all stated that medications should not be kept unlocked in resident rooms and should instead be locked in a med cart or, for residents with self-administration orders, in a locked box. The facility’s written policy requires all drugs and biologicals to be stored in locked compartments and specifies that compartments containing medications must be locked when not in use.
Surveyors found that the facility's designated resident smoking area in the courtyard lacked a required self-closing metal butt can for cigarette disposal, as mandated by NFPA 101. The Maintenance Director confirmed the absence of this fire safety equipment during the inspection.
A resident with right-sided hemiplegia and aphasia, dependent on staff for ADLs, did not receive ordered passive range of motion (PROM) exercises or brace application as documented in the care plan and physician's orders. Staff interviews revealed a lack of awareness and implementation of these interventions, and review of the Treatment Administration Record showed no documentation of the required care, resulting in a deficiency for failure to maintain or improve range of motion.
Surveyors identified expired medications in two medication carts during a review, including an expired bottle and a gel for a resident that was past its use date. The facility's policy requires checking expiration dates before administration, but the DON confirmed expired medications should not be present and noted that cart checks occur weekly but need better follow-through.
A medication error rate of 8% was identified when an LPN crushed and administered two extended-release medications to a resident, despite both being contraindicated for crushing. The facility's policies and physician orders required staff to avoid altering medications when contraindicated, and both the consultant pharmacist and DON confirmed the error. This deficiency was observed during a survey and was based on direct observation, record review, and staff interviews.
The facility did not ensure RN coverage for at least 8 consecutive hours on two reviewed days, as required by federal regulations. Staffing records and time sheets showed that on these days, RN hours fell short, and staff interviews confirmed no other RN was present to meet the requirement.
A resident with significant physical and cognitive impairments did not receive prescribed passive range of motion exercises or brace application as ordered in their care plan and physician's orders. Staff were unaware or did not implement the required interventions, and documentation confirming these treatments was absent.
A resident with a right hand contracture and history of stroke did not receive ordered passive range of motion (PROM) exercises or splint/brace application as documented in the care plan and physician's orders. Staff interviews revealed a lack of awareness and implementation of these interventions, and review of records confirmed no documentation of PROM or splint use during the review period.
The facility did not provide RN services for the required 8 consecutive hours on two days, as staffing records and time sheets confirmed that RN coverage fell short. Staff interviews verified that no other RN was present and no call-offs occurred, resulting in a deficiency in meeting minimum RN staffing requirements.
Surveyors found expired Acetaminophen and Lorazepam topical gel on two medication carts, despite facility policy requiring expiration date checks before administration. The DON confirmed expired medications should not be present and noted that weekly cart checks were not consistently followed.
A medication error rate of 8% was identified when an LPN crushed and administered two extended-release medications—Metoprolol Succinate ER and Klor-Con M20—by mixing them in pudding for a resident, despite facility policy and drug guidelines contraindicating this practice. Both the consultant pharmacist and DON confirmed that these medications should not have been crushed, and alternative forms should have been used.
A resident with a history of falls and medical conditions fell and sustained a major injury due to inadequate supervision and assistance. Despite having a care plan with interventions, the resident attempted to go to the bathroom unassisted, resulting in a fall. The facility failed to document specific interventions or monitoring frequency, and the resident's call light was not within reach. Staff monitoring was inconsistent, and no new interventions were added to the care plan to prevent further incidents.
A resident with a history of falls and sensory impairments fell while attempting to use the bathroom unassisted, resulting in a major injury. Despite having a care plan that included assistance with toileting and the use of a call bell, the resident was found on the floor with the call light not engaged. Staff interviews revealed inconsistent monitoring, and the care plan had not been updated with new interventions to prevent further falls.
The facility failed to provide a clean and comfortable environment, with issues such as stained floors, peeling wallpaper, and malfunctioning equipment. A resident reported difficulties with a non-functioning bed control, which had been unresolved despite informing staff. The Administrator acknowledged the environmental concerns and a failure in the work order process.
Insufficient Nursing Staff and Call Light Accessibility Failures
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff and ensure accessible, functional call lights for dependent residents, as required by its own call light policy and federal regulations. The facility’s written policy states that residents must have a call light within reach, that call lights must be answered promptly by facility personnel, and that all personnel are expected to respond. During an initial tour at 8:45 a.m., multiple dependent residents were observed in bed with their call lights on the floor and not accessible, and the DON confirmed that these residents should have had call bells within reach. Photographic evidence was obtained of call lights on the floor. Multiple residents reported prolonged delays in call light response and difficulty obtaining assistance. One resident stated she had recently filed a grievance about call light response times and reported waiting about 30 minutes to an hour before anyone answered, sometimes having to walk to the nurses’ station herself. Another resident reported waiting “hours” after pressing the call bell and said that when staff did not come, she would go to the desk in her wheelchair; she believed there was not enough help at night and on weekends. A third resident reported that sometimes it took a very long time for staff to answer the call light, and that on one occasion when he did not have a call bell at his side, he yelled repeatedly and ultimately called 911 from his phone to get help. Additional residents described ongoing problems with unanswered call lights and unmet care needs. One resident reported that it could take up to an hour for staff to respond and that at the time of interview he had been waiting about an hour for a simple request for water; when he activated his call light, the indicator above the door did not illuminate until an RN adjusted the wall connection, confirming the call light had not been working. Another resident stated he had filed grievances about staff not answering call lights and reported that he sometimes waited two hours or more for toileting assistance, resulting in soiling himself; he said he did not think there was enough staff and that this had been an ongoing issue. Nursing staff interviews further described workload and response-time issues. One LPN stated that all staff are responsible for answering call bells, that the required response time was within 30 minutes, and that she had to triage which residents to see first; she reported sometimes being unable to respond timely and described working night shift with 35–38 residents, saying she did not feel her license or the residents were safe. Another LPN stated that everyone was responsible for answering call lights and that the expectation was a response within 10 minutes, but that this did not occur because staff were too busy; she reported caring for 20–29 residents per shift and had told management that, given resident acuity and needs, this was too many. Review of the grievance logs showed repeated, non-specific complaints about call bell issues over multiple review periods. For one review period, there were seven call light grievances, all documented as “call bell issues” and handwritten by the Activities Director, without specific times or dates. The facility’s documented resolution for these grievances was staff education and call bell audits, but the same audit documentation was used across different review periods, and for some periods there was no documentation that audits or education were actually completed. The Activities Director stated she wrote all resident grievance forms, knew many residents had issues with timeliness of call light response, and that residents could not recall specific times or dates. She reported that during resident council meetings, residents continued to voice that delayed call light response remained an ongoing problem. In an interview, the Administrator acknowledged that answering call lights was a “work in progress” and stated that they kept educating staff. He noted that when the issue was raised in resident council, residents would start to complain about it and that there were many similar complaints on the same day, sometimes from the same residents. He also stated that he could only staff according to what his management allowed. The DON reiterated that call lights should be within reach of each resident and answered as quickly as possible, stating that any time a call light is set off it could be an emergency. Despite these stated expectations, the observations, resident interviews, staff interviews, and grievance documentation collectively showed that dependent residents did not consistently have accessible, functional call lights and experienced significant delays in staff response, reflecting insufficient nursing staff to meet residents’ needs.
Unsecured Medications Left in Resident Rooms
Penalty
Summary
Surveyors identified a deficiency in the facility’s safe storage of medications when multiple residents were observed with unsecured medications at bedside. On two consecutive days, one resident’s room was observed to contain an unlocked bottle of Melatonin 10 mg gummies and a bottle of brand-name eye vitamin soft gels on the nightstand. Another resident’s room was observed on two days with an unsecured bottle of Allergy Nasal Mist (Oxymetazoline HCl 0.05% nasal decongestant) on the overbed table. A third resident’s room was observed on two days with an unlocked bottle of Antacid Extra Strength tablets, a box of Aspirin Pain Reliever/Caffeine/Pain Reliever Aid arthritis powder, and a bottle of vaporizing rub on the overbed table. Photographic evidence was obtained for each of these observations. In interviews, LPN staff members acknowledged that these medications should not have been stored in residents’ rooms and stated that medications should be locked in the medication cart at all times. The Assistant Director of Nursing stated that medications should not be in any resident’s room unless the resident has an order to self-administer, in which case they must be locked in a box in the room; otherwise, medications are to be locked in the medication cart. The Director of Nursing stated that medications should never be left in a resident’s room unlocked and should be locked at all times. Review of the facility’s “Medication Storage and Labeling” policy, issued 3/21 and revised 1/24, documented that all drugs and biologicals are to be stored in locked compartments, with compartments containing drugs and biologicals locked when not in use and unlocked medication carts never left unattended.
Noncompliance with Smoking Area Fire Safety Requirements
Penalty
Summary
During a fire life safety survey, it was observed that the facility failed to comply with National Fire Protection Association (NFPA) 101 smoking regulations. Specifically, the established smoking area in the courtyard, which was the only designated area for residents to smoke, did not have a self-closing metal butt can as required by the standard. This deficiency was identified during a facility tour conducted between 1:00 p.m. and 5:00 p.m. with the Maintenance Director present. The surveyor noted that the absence of a self-closing metal container for cigarette disposal in the smoking area was a direct violation of NFPA 101 (2012 and 2021 Editions) section 19.7.4(6). The regulation mandates that metal containers with self-closing cover devices, into which ashtrays can be emptied, must be readily available in all areas where smoking is permitted. The report also clarified that smoking tower disposal receptacles do not meet the requirement for ashtrays or self-closing metal containers. The Maintenance Director acknowledged the findings during the interview that was conducted concurrently with the observations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency were provided in the report. The deficiency was based solely on the lack of required fire safety equipment in the designated smoking area.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On , an order was placed for two new red cigarette butt cans by the Director of Maintenance. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On , the Maintenance Director, and Administrator will conduct an audit on facility's red cigarette butt cans to identify potential issues with the cans and to ensure they are opening and closing fully. Any issues identified were corrected. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On, facility staff were educated on the components of K0741 to ensure a safe, comfortable, and compliant smokers' area with emphasis on reporting equipment concerns through the electronic work order system for follow-up by the Assistant Director of Nursing. Newly hired staff will be educated by the Assistant Director of Nursing/Designee on the components of K0741 during orientation with an emphasis on ensuring a safe smoking area environment by reporting physical environment concerns through the electronic work order system as part of the systematic change. 4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Maintenance Director/Designee will conduct audits of the physical environment of the smoking area 1 time/week for 4 weeks, then monthly for 2 months to ensure that no homelike environment concerns exist and compliance with Federal Regulation K0741. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines that substantial compliance has been met. The cans and to ensure they are opening and closing fully. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On, facility staff were educated on the components of K0741 to ensure a safe, comfortable, and compliant smokers' area with emphasis on reporting equipment concerns through the electronic work order system for follow-up by the Assistant Director of Nursing. Newly hired staff will be educated by the Assistant Director of Nursing/Designee on the components of K0741 during orientation with an emphasis on ensuring a safe smoking area environment by reporting physical environment concerns through the electronic work order system as part of the systematic change. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Maintenance Director/Designee will conduct audits of the physical environment of the smoking area 1 time/week for 4 weeks, then monthly for 2 months to ensure that no homelike environment concerns exist and compliance with Federal Regulation K0741. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines that substantial compliance has been met. On, facility staff were educated on the components of K0741 to ensure a safe, comfortable, and compliant smokers' area with emphasis on reporting equipment concerns through the electronic work order system for follow-up by the Assistant Director of Nursing. Newly hired staff will be educated by the Assistant Director of Nursing/Designee on the components of K0741 during orientation with an emphasis on ensuring a safe smoking area environment by reporting physical environment concerns through the electronic work order system as part of the systematic change. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Maintenance Director/Designee will conduct audits of the physical environment of the smoking area 1 time/week for 4 weeks, then monthly for 2 months to ensure that no homelike environment concerns exist and compliance with Federal Regulation K0741. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines that substantial compliance has been met.
Failure to Provide and Document Range of Motion Interventions
Penalty
Summary
A deficiency was identified when the facility failed to provide appropriate treatment and services to prevent a decline in range of motion for a resident with limited mobility. The resident, who had a history of right-sided hemiplegia and aphasia following a cerebrovascular event, was dependent on staff for activities of daily living and had documented functional limitations in the upper and lower extremities on one side. The care plan and physician's orders specified that the resident should receive passive range of motion (PROM) exercises and application of a brace to the right side, with specific instructions for timing and monitoring. Despite these documented interventions, observations and record reviews revealed that the resident did not receive the ordered PROM or brace application. The Minimum Data Set (MDS) assessment indicated that the resident had not received passive or active range of motion or brace assistance for at least 15 minutes in the previous seven days. Interviews with staff members, including CNAs and LPNs, showed a lack of awareness or implementation of the prescribed interventions, with one CNA stating that the resident did not have anything in place for the right side at the time of observation, and an LPN not being aware of any device for the resident's right side. Further review of the Treatment Administration Record (TAR) confirmed the absence of documentation that PROM or brace application had been performed as ordered. The Director of Nursing verified the lack of documentation and confirmed that the resident had an active order for these interventions. The failure to provide and document the required care and services led to the deficiency under the federal regulation for maintaining or improving range of motion and mobility.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. F688 Increase/Prevent Decrease in ROM/Mobility (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On , Resident # 31 was assessed by a licensed nurse. No concerns were noted related to the alleged deficient practice. On the order was clarified with MD to indicate donning and doffing of , as well as performing PROM. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken, On Audit was completed by Director of Nursing/designee on residents who had orders for /braces to ensure order indicated donning and doffing equipment. Any issues identified were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By Current Nurses and staff will be educated on the components of F688 with an emphasis on documenting the donning and doffing of a /brace and following the comprehensive resident centered care plan and Prevention of decrease in ROM/Mobility by the DON/Designee. Newly hired licensed nurses/ . Staff will be educated on the components of F688 with an emphasis on documenting the donning and doffing of a /brace and following the comprehensive resident centered care plan and prevention of decrease in ROM/Mobility by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct audits of 5 residents with physician orders for a /brace 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that the physician order includes documentation of donning and doffing /brace. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Expired Medications Found in Medication Carts
Penalty
Summary
Surveyors found that the facility failed to remove expired medications from two of four medication carts reviewed, specifically the "Colonial 1" and "Heritage" carts. During observations, one bottle with an expired date was found on the Colonial 1 cart, and a bottle of gel 0.5 mg/mL for a resident was found on the Heritage cart with packaging that specified it should not be used after a certain date. Photographic evidence was obtained for both findings. The facility's policy requires that the expiration or beyond-use date on medication labels be checked prior to administration. In an interview, the DON acknowledged that expired medications should not be present in the medication carts and stated that medication carts are checked on Sundays, but indicated there was a need to improve follow-through with these checks.
Plan Of Correction
F755-Pharmacy Services/Procedures/Pharmacist/Records (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On the expired and gel were removed from the medication carts. Audit was conducted of remaining medication carts with no other concerns were noted related to the alleged deficient practice. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; An audit was completed by the Director of Nursing/designee on all medication carts and medication rooms to ensure there were no outdated or expired medications. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By current licensed nurses will be educated on the components of F755 with an emphasis on monitoring medications for expiration dates and appropriate medication storage by the DON/Designee. Newly hired licensed nurses will be educated on the components of F755 with an emphasis on monitoring medications for expiration dates and appropriate medication storage by the DON/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Director of Nursing/Designee will conduct audits of medication carts and medication weekly for 4 weeks, then once a week for 4 weeks, and then monthly for 1 month to ensure that there are no expired or outdated medications present and medications are stored properly. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Medication Error Rate Exceeds 5% Due to Improper Crushing of Extended-Release Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by federal regulations, resulting in an observed error rate of 8% out of 25 opportunities. During medication administration, an LPN was observed crushing and administering two extended-release medications to a resident, despite both medications being contraindicated for crushing. The physician's order allowed for medications to be crushed or diluted unless contraindicated, but the extended-release formulations specifically should not have been altered in this way, as confirmed by reference sources and the facility's consultant pharmacist. The facility's policies require medications to be administered according to prescriber orders and for staff to consult with a physician or pharmacist if there are concerns about medication appropriateness or potential adverse consequences. Both the consultant pharmacist and the Director of Nursing confirmed that the extended-release medications should not have been crushed and that alternative formulations or orders should have been sought. The incident was identified during an unannounced recertification survey, and the deficiency was based on direct observation, record review, and staff interviews.
Plan Of Correction
F759-Free of Medication Error Rate of 5% or More (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On Staff A was educated regarding medication administration and the "Do not Crush" list on medication cart. On Resident #22 was assessed by a licensed nurse with no negative findings. MD was notified of medication error with orders received to change the form of the 2 identified medications. Started treatment on . (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On Audit was completed by Director of Nursing/designee on current residents to identify if medications needed to be crushed. Any identified meds were changed to the appropriate form. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By , Current Licensed Nurses will be educated on the components of F759 with an emphasis on being aware of what medications can be crushed and which medications can not be crushed as well as overall medication administration practices by the DON/Designee. Newly hired licensed Nurses will be educated on the components of F759 with an emphasis on being aware of what medications can be crushed and which medications can not be crushed as well as overall medication administration practices by the DON/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct observations of medication administration 3x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that licensed Nurses are administering medications properly. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Provide Required RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) provided services for at least 8 consecutive hours per day, 7 days a week, as required by federal regulations. Record review of staffing forms and RN time sheets revealed that on two separate days, the number of RN hours worked fell below the required 8 consecutive hours. Specifically, on one day, only 7.87 hours were worked, and on another, only 5.42 hours were worked. Further examination of RN time sheets confirmed that on these days, the RN clocked in and out in a manner that resulted in less than the required consecutive hours of coverage. Interviews with the Labor Coordinator and the Nursing Home Administrator confirmed that no other RN worked on those days to supplement the hours, and there were no call-offs reported. The Labor Coordinator acknowledged the discrepancy as a mistake, and the Administrator verified the shortfall in RN coverage. The deficiency was identified through review of facility records and staff interviews, with no mention of resident-specific incidents or medical histories related to the deficiency.
Plan Of Correction
F727-RN 8 Hrs/7 days/wk What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Administrator completed a comprehensive review of RN hours for the previous 2 weeks and found that there were 8 consecutive hours of RN coverage. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On , Audit was completed by Administrator/designee of Staffing hours for past 2 weeks to ensure that Staffing requirements are met, Including 8 consecutive RN hours every day of the week day. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By /205, the Staffing coordinator, Administrator and Human Resources and Director of Nursing will be educated on the components of F727 with an emphasis on 8 consecutive hours seven days a week of RN hours per day and schedule requirements by the Regional Vice President of Operations/Designee. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Administrator/Designee to conduct audits of staffing report 5x a week for 4 weeks, then 2x a week for 4 weeks and then monthly for 1 month to ensure that Staffing requirements are met and that there are 8 consecutive RN hours every day of the week. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Provide Ordered Range of Motion and Brace Application
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent a decline in range of motion for a resident with significant physical and cognitive impairments. The resident, who had a history of hemiplegia, hemiparesis, and aphasia, was dependent on staff for activities of daily living and had documented functional limitations in the upper and lower extremities on one side. The care plan and physician's orders specified that the resident should receive passive range of motion (PROM) exercises and application of a brace to the affected limb, with specific instructions for timing and monitoring. However, observations revealed that the resident did not have the prescribed device in place, and staff interviews indicated a lack of awareness or implementation of the required interventions. Review of documentation, including the Treatment Administration Record (TAR) and CNA Kardex, showed no evidence that PROM or brace application had been performed as ordered. Staff interviews confirmed that the interventions were not being carried out, and the Director of Nursing verified the absence of documentation for these treatments. As a result, the facility did not meet the licensure requirement to provide adequate and appropriate health care and services consistent with the resident's care plan and physician's orders.
Plan Of Correction
F688 Increase/Prevent Decrease in ROM/Mobility (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On , Resident # 31 was assessed by a licensed nurse. No concerns were noted related to the alleged deficient practice. On , the order was clarified with MD to indicate donning and doffing of , as well as performing PROM. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: On Audit was completed by Director of Nursing/designee on residents who had orders for /braces to ensure order indicated donning and doffing equipment. Any issues identified were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: By , Current Nurses and staff will be educated on the components of F688 with an emphasis on documenting the donning and doffing of a /brace and following the comprehensive resident centered care plan and Prevention of decrease in ROM/Mobility by the DON/Designee. Newly hired licensed nurses/ , Staff will be educated on the components of F688 with an emphasis on documenting the donning and doffing of a /brace and following the comprehensive resident centered care plan and prevention of decrease in ROM/Mobility by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct audits of 5 residents with physician orders for a /brace 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that the physician order includes documentation of donning and doffing /brace. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Provide Ordered Range of Motion and Splinting Interventions
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent a decline in range of motion for a resident with a right hand/wrist contracture and a history of hemiplegia and hemiparesis following a stroke. The resident was dependent on staff for activities of daily living and had severely impaired cognitive skills, making them rarely or never understood. The care plan and physician's orders specified that passive range of motion (PROM) and splint/brace application should be performed, with detailed instructions for timing and monitoring. However, observations revealed that the resident did not have a splint in place, and staff interviews indicated a lack of awareness or implementation of the splinting intervention. The resident was noted to experience significant pain with hand movement, and there was no evidence that PROM or splint/brace application had been provided as ordered. Review of documentation, including the Treatment Administration Record (TAR), showed no record of PROM or splint application for the resident during the specified period. Staff interviews confirmed that the interventions were not being carried out, and the Director of Nursing verified the absence of documentation for these required treatments. The facility's failure to follow the care plan and physician's orders resulted in a lack of appropriate care to maintain or improve the resident's range of motion.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours on two separate days during a 14-day staffing review period. Review of staffing records and RN time sheets showed that on the specified dates, the RN coverage was 7.87 hours and 5.42 hours, respectively, both falling short of the required 8 consecutive hours. Interviews with the Labor Coordinator confirmed that no other RN worked on those days and there were no call-offs, indicating a scheduling error. The Nursing Home Administrator verified the deficiency in RN coverage for those days.
Expired Medications Found on Medication Carts
Penalty
Summary
Surveyors observed that the facility failed to remove expired medications from two of four medication carts reviewed. Specifically, one bottle of Acetaminophen with an expiration date of 5/2025 was found on the Colonial 1 medication cart, and one bottle of Lorazepam topical gel labeled 'Do not use after 7/10/25' was found on the Heritage medication cart for a resident. The facility's Medication Administration policy requires staff to check expiration or beyond use dates prior to administering medications. During an interview, the Director of Nursing acknowledged that expired medications should not be present in the carts and stated that medication carts are checked weekly, but follow-through on these checks needs improvement.
Medication Error Rate Exceeds 5% Due to Improper Crushing of Extended-Release Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 8% out of 25 opportunities. During medication administration, an LPN was observed crushing and administering two extended-release medications—Metoprolol Succinate ER 25 mg and Klor-Con M20 (Potassium Chloride Extended Release)—to a resident by mixing them in pudding. The physician's order allowed medications to be crushed or diluted as needed unless contraindicated. However, both medications are extended-release formulations, and crushing them is contraindicated according to standard drug references. Interviews with the Consultant Pharmacist and the Director of Nursing confirmed that extended-release tablets should not be crushed, and alternative formulations should have been sought if the resident was unable to swallow the tablets whole. The facility's policies require medications to be administered as prescribed and for any deviations or concerns to be documented and communicated to the prescriber. These procedures were not followed in this instance, resulting in a medication error that contributed to the facility's elevated error rate.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent accidents for a resident with a history of falls and other medical conditions. The resident, who was legally blind and hard of hearing, had a care plan that included interventions such as assistance with toileting and reminders to use the call bell for help. However, the resident attempted to go to the bathroom unassisted, resulting in a fall and a major injury that required hospital admission and surgical repair. The incident occurred when a registered nurse found the resident on the floor in front of the bathroom door, with the call light not engaged. The resident had attempted to go to the bathroom unassisted, despite being known to require assistance. The Director of Nursing (DON) acknowledged that the resident had toileting times in place and was known to be at risk, but there was no documentation of specific interventions or monitoring frequency. The resident's room was moved closer to the nursing station after the incident, but the call light was still not within reach, and the privacy curtain and room door made observation difficult. Interviews with staff revealed that monitoring and supervision were inconsistent, with no set times for checking on the resident. The facility's Quality Assurance Performance Improvement Plan showed no reduction in incidents, and education was provided to staff, but there was no documentation of new care plan interventions to prevent further accidents. The facility's failure to implement and document adequate supervision and interventions contributed to the resident's fall and injury.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On Resident #850 was immediately assessed by a licensed nurse. No concerns were noted related to the alleged deficient practice. On Resident #8500's care plan was reviewed with the Interdisciplinary Team and revised to reflect appropriate interventions to minimize risk of. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: On a quality review was completed by Director of Nursing/designee on Residents identified to be at increased risk for to ensure that appropriate interventions have been put into place and reflected on the care plan. Any issues identified were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By, Licensed Nurses and Certified Nursing Assistants were educated on the components of F689 with an emphasis on identifying a change in condition and providing increased supervision and interventions to minimize the risk for by the Director of Nursing/Designee. Newly hired licensed nurses and Certified Nursing Assistants will be educated on the components of F689 with an emphasis on identifying a change in condition and providing increased supervision and interventions to minimize the risk for by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct audits of 5 residents care plans 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that appropriate interventions were put into place to minimize risk of. The findings of these quality monitoring...s to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance to a resident, identified as Resident #850, who had a history of falls and was legally blind and hard of hearing. The resident's care plan included interventions such as assistance with toileting, encouraging the use of a call bell, and wearing appropriate footwear. Despite these interventions, the resident attempted to go to the bathroom unassisted, resulting in a fall and a major injury requiring hospital admission and surgical repair. The incident occurred when a Registered Nurse found the resident on the floor in front of the bathroom door, with the call light not engaged. The resident had attempted to go to the bathroom unassisted, despite being known to require assistance. The Director of Nursing acknowledged that the resident had no prior falls since admission and that interventions were in place, but there was no documentation of specific supervision or monitoring times. The resident's room was moved closer to the nursing station after the incident, but the call light was still not within reach, and the privacy curtain and door were often closed, making observation difficult. Interviews with staff revealed that monitoring and supervision were inconsistent, with no set times for checking on the resident. The Director of Rehab noted that the resident required assistance with all activities and could roll over in bed with minimal help. Despite the facility's efforts to educate staff on fall prevention, the care plan for Resident #850 had not been updated with new interventions to prevent further falls, and there was no documentation of increased supervision or monitoring.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #850 was immediately assessed by a licensed nurse. No concerns were noted related to the alleged deficient practice. Resident #850's care plan was reviewed with the Interdisciplinary Team and revised to reflect appropriate interventions to minimize risk of. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: A quality review was completed by Director of Nursing/designee on Residents identified to be at increased risk to ensure that appropriate interventions have been put into place and reflected on the care plan. Any issues identified were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Licensed Nurses and Certified Nursing Assistants were educated on the components of N201 with an emphasis on identifying a change in condition and providing increased supervision and interventions to minimize the risk by the Director of Nursing/Designee. Newly hired licensed nurses and Certified Nursing Assistants will be educated on the components of N201 with an emphasis on identifying a change in condition and providing increased supervision and interventions to minimize the risk by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct audits of 5 residents' care plans 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that appropriate interventions were put into place to minimize risk of. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Environmental and Maintenance Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a clean, sanitary, and comfortable environment for its residents, as evidenced by multiple environmental issues observed during a tour. These issues included stained and cracked floors in the activity room, missing and peeling cove base in several rooms, a dried black substance on a handrail, peeling wallpaper with orange discoloration in common hallways, and dirty, scuffed walls in various rooms. Additionally, corners and crevices where floors meet walls were found to have caked-in dirt. Photographic evidence was obtained to document these deficiencies. A resident reported that his bed had not been functioning properly since his arrival at the facility a few months prior. The control to adjust the bed's head position was not working, requiring the resident to physically get out of bed to make adjustments, which was difficult for him. Despite informing multiple staff members, including the Administrator, the issue remained unresolved. Interviews with staff revealed a lack of awareness and communication regarding the bed's malfunction, with the Maintenance Director only becoming aware of the issue during the survey. The Administrator acknowledged the environmental concerns and noted a failure in the work order process, which contributed to the unresolved maintenance issues.
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Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
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