Boca Circle Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Boca Raton, Florida.
- Location
- 7225 Boca Del Mar Drive, Boca Raton, Florida 33433
- CMS Provider Number
- 105852
- Inspections on file
- 24
- Latest survey
- May 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Boca Circle Rehabilitation Center during CMS and state inspections, most recent first.
Three residents who were unable to perform their own activities of daily living did not receive adequate nail care, as evidenced by observations of long or dirt-encrusted nails. Staff interviews revealed inconsistent practices and a lack of a defined schedule for nail care, despite facility policy requiring assistance with personal hygiene for dependent residents.
Three residents with active wounds or indwelling devices did not have required Enhanced Barrier Precaution (EBP) orders in place, despite facility policy. Observations showed missing EBP signage and PPE in some rooms, and residents reported staff did not consistently use gowns during care. The Infection Preventionist confirmed these residents should have had EBP orders, but records and interviews revealed the deficiency.
Two residents experienced severe weight loss due to the facility's failure to provide adequate nutritional support and timely interventions. One resident, with cognitive and physical impairments, lost 10.8% of body weight in less than two months, while another resident lost 9.8% in one month. The facility did not provide necessary assistance during meals or implement nutritional supplements promptly, and communication lapses among staff led to inadequate monitoring and documentation of weight changes.
The facility failed to provide adequate nutritional support for two residents experiencing significant weight loss and did not ensure competency verification for a resident performing self-care for a tracheostomy. One resident experienced a 6.7% weight loss over six weeks, with no nutritional supplements ordered despite observable difficulties in eating. Another resident had a 9.8% weight loss in one month, with delayed nutritional interventions. Additionally, a resident was changing her tracheostomy inner cannula without recent competency verification, as the last documented competency was over a year ago.
A facility failed to maintain the dignity and privacy of a resident with hemiplegia and hemiparesis. The resident was observed twice lying uncovered and without underwear, with the door open, and playing with a Foley catheter. A CNA confirmed the importance of privacy and stated that residents should not be exposed, especially if they are not fully conscious.
A facility failed to appoint a guardian for a resident with severe cognitive impairment in a timely manner. The resident's family was not involved, and the only listed representative had requested removal from the contact list. The facility had been attempting to address the issue since early 2024 but faced difficulties in finding an attorney. The Administrator was unaware of the resident's need for guardianship until the day of the interview, and the facility lacked a policy on guardianship.
A facility failed to complete a Level 2 PASARR for a resident admitted with serious mental illness and other conditions. Although a Level 1 PASARR was conducted at the hospital, the resident's stay exceeded the anticipated period, requiring a Level 2 PASARR, which was not completed. The Social Service Director confirmed the oversight and the absence of the necessary documentation.
A facility failed to provide necessary dining assistance for two residents, including one with moderately impaired mental status requiring supervision. Observations showed a resident left unattended with meal trays, while staff interviews revealed inconsistencies in understanding the required level of assistance. CNAs responsible for dining support were not consistently present, leading to a deficiency in care.
A facility failed to ensure a resident's competency in changing her tracheostomy inner cannula. The resident, with a history of Respiratory Failure and Tracheostomy Status, was changing her cannula more frequently than instructed, without recent competency verification. The facility could not locate documentation of her competency, and the resident was re-educated only after surveyor intervention.
A facility failed to monitor and document the behaviors and side effects of a resident on psychotropic medications. Despite a care plan requiring such monitoring, records for two months showed no documentation. An LPN confirmed the monitoring process but could not provide evidence for this resident. The facility's Administrator was informed of the deficiency.
The facility failed to provide the correct pureed diet consistency for three residents, serving lumpy Chicken Pot Pie with identifiable green bean shells. Despite the Speech Therapist's acknowledgment of the need for uniform consistency and the District Manager's routine checks, the deficiency persisted. The residents involved had various medical conditions and were unable to conduct interviews due to their mental status.
The facility failed to meet the dietary preferences and needs of four residents, as observed during dining. A resident with severe cognitive impairment did not receive the fortified mashed potatoes listed on their meal ticket, while another resident was missing ice cream. A third resident expressed frustration over receiving unwanted green vegetables, and a newly admitted resident reported receiving inedible food that did not match their preferences. Despite a process involving multiple checkpoints, LPNs did not verify meal consistency, leading to these deficiencies.
The facility failed to deliver meal trays on time during two observations, with significant delays reported across various dining areas. Two cognitively intact residents expressed concerns about consistently late lunch deliveries. The kitchen District Manager admitted to changing meal times for breakfast and dinner but forgot to adjust lunch timings, leading to the observed discrepancies.
The facility failed to dispose of garbage and refuse properly, as a construction dumpster was used for kitchen waste, leading to foul smells and insect attraction. The maintenance director had informed the kitchen staff multiple times about the correct use of the dumpster, but the issue persisted. The facility's Administrator was made aware of the findings.
The facility failed to follow proper hand hygiene and infection control protocols during medication administration and dialysis disconnection for three residents. Staff members were observed not performing hand hygiene during respiratory treatments, directly touching medications with gloved hands, and not changing gloves after touching non-sterile surfaces during dialysis disconnection.
A resident was observed lying on her bed without underwear or a blanket, with the door open, on two occasions. The resident was fully dependent on assistance for mobility. A CNA acknowledged the importance of maintaining residents' dignity and privacy, stating that doors should be closed when providing care and that residents should always wear underwear.
The facility failed to maintain its commercial cooking facility according to NFPA 101 standards. During a fire safety tour, it was found that the seams of the kitchen's commercial cooking hood suppression system were not sealed or greasetight. The Maintenance Director acknowledged the issue, which was reviewed with the Administrator and Regional Maintenance Director.
The facility failed to maintain and test their Essential Electrical System as per NFPA 99 standards, lacking documentation for weekly voltage checks and monthly conductance tests for two generator batteries. The Regional Director of Maintenance acknowledged these findings during a record review.
The facility did not maintain egress doors with delayed egress locking arrangements as per NFPA 101 standards. Observations revealed missing required signage on several doors and a failure of the Therapy Lobby doors to open when tested. These issues were acknowledged by the Maintenance Director and reviewed with facility leadership.
The facility failed to maintain the integrity of their fire/smoke barriers, as observed during a fire safety tour. Penetrations were found in the 1-hour smoke walls in two hallways, compromising their fire resistance rating. The Maintenance Director acknowledged these findings, and the issue was discussed with the facility's leadership.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care to three out of four sampled residents who were unable to perform activities of daily living independently. Observations revealed that one cognitively intact resident had long nails and reported that staff only cleaned her nails, though she sometimes wanted them cut. Another resident, who was moderately cognitively impaired and required set-up assistance for personal hygiene, was observed with dirt-encrusted and unkempt nails. A third resident, who was severely cognitively impaired and required dependent assistance, was also observed with heavily dirt-encrusted nails. Interviews with staff indicated that certified nursing assistants (CNAs) were responsible for providing nail care, but there was no consistent schedule or time frame for this care, with staff stating it was done "as needed" or approximately every three days. Staff members acknowledged during observations that the residents' nails were dirty and needed attention. The facility's policy required that residents unable to perform activities of daily living receive necessary services to maintain grooming and hygiene, but this was not consistently implemented for the residents observed.
Failure to Implement Enhanced Barrier Precautions for Residents with Wounds
Penalty
Summary
The facility failed to implement and maintain Enhanced Barrier Precautions (EBP) for residents with active wounds, as required by their own infection prevention and control policy. Specifically, three out of four sampled residents with wounds or indwelling medical devices did not have EBP orders in place. For one resident with a stage 2 pressure ulcer and on dialysis, there were no EBP orders, no signage, and no personal protective equipment (PPE) observed in or outside the room, and the resident reported that staff did not wear gowns during direct care. Another resident with multiple unhealed pressure ulcers and a suprapubic catheter also lacked EBP orders, and although signage and PPE were present, the resident stated that staff did not wear gowns during care. A third resident with unhealed pressure ulcers similarly had no EBP orders, though signage and PPE were observed in the room. Record reviews and interviews confirmed that the facility's policy required EBP for residents with wounds or indwelling devices, including clear signage and availability of PPE. The Infection Preventionist acknowledged during interview and record review that all three residents should have had EBP orders in place, and could not provide additional information to explain the lack of compliance. The care plans for these residents referenced following facility protocols for skin breakdown prevention and, in one case, noted the need for EBP, but the required orders and consistent implementation were not present.
Failure to Address Severe Weight Loss in Residents
Penalty
Summary
The facility failed to identify and address severe weight loss in a timely manner for two residents, leading to significant nutritional deficiencies. Resident #52, who was admitted with cognitive and physical impairments, experienced a 10.8% weight loss over less than two months. Despite observations of the resident's inability to eat independently due to uncontrollable hand tremors, the facility did not provide adequate assistance during meals or implement nutritional supplements. The Registered Dietitian was not informed of the resident's severe weight loss and did not take timely action to address the nutritional needs. Resident #56 also experienced a severe weight loss of 9.8% in one month and an overall 12% weight loss over six months. The facility's interventions were delayed, with nutritional supplements not being ordered until over a month after the significant weight loss was identified. The resident's meal intake was consistently below 50%, yet the facility failed to ensure the prescribed fortified foods and supplements were consistently provided. The facility's policies on weight monitoring and nutritional assessment were not effectively implemented, leading to a lack of timely interventions for residents experiencing significant weight loss. The Registered Dietitian and staff failed to communicate and document weight changes and nutritional needs adequately, resulting in continued weight loss and potential malnutrition for the residents involved.
Plan Of Correction
Boca Circle Rehabilitation Center failed to identify a severe loss in a timely manner and failed to provide adequate nutritional supplements to prevent further severe loss. **Actions Taken:** 1) Resident #52 was evaluated by the Registered Dietitian on and additional nutritional interventions were implemented. A comprehensive nutritional assessment was completed for Resident #52 on and the resident now attends the dining room for his meals for oversight and assistance as needed. On resident #52 was placed on an appetite stimulant. Resident #52 was placed on weekly and is currently receiving Occupational and Speech therapies. The Resident's responsible party has been updated. Resident #56 was evaluated by the Registered Dietitian on and additional nutritional interventions were implemented. A comprehensive nutritional assessment was completed for Resident #56 on the resident was seen by the Speech Pathologist and her diet was downgraded to Puree and on the resident was placed on an appetite stimulant. Resident #56 is currently receiving Occupational and Speech therapies. The Resident's responsible party has been updated. **Others Identified:** 2) Full house audit completed between by the Registered Dietitian/Designee to identify residents that may have been affected due to delayed loss intervention or missing a nutritional intervention in the electronic medical record or ticket system recommended by the Registered Dietitian. Additional documentation recommended from the full house audit was completed by facility Registered Dietitian by Regional Dietitian completed a full house audit between to ensure residents have been per protocol and monitored appropriately to identify severe loss. Any concerns identified were immediately addressed. **Measures Taken:** 3) Regional Dietitian in-serviced the Registered Dietitian on regarding timely nutrition interventions with a focus on residents with loss as well as ensuring nutritional interventions are placed in electronic medical record and ticket system timely as applicable. Nursing staff were re-educated to refer to resident Kardex in reference to amount of assistance required with meals initiated on by Ellie Schutt, LNHA/Designee. **Ongoing Monitoring:** 4) The Registered Dietitian/Designee will conduct an audit of 10 residents on each unit weekly to ensure the residents with loss have timely documentation with nutritional interventions and verify that the nutritional interventions are placed in the EMR and the ticketed system timely weekly x 4 weeks, and then every 2 weeks x 2 months. Findings of the audits will be reviewed in the QAPI Meetings to ensure substantial compliance. The QAPI committee is responsible for the ongoing compliance.
Failure to Provide Adequate Nutritional Support and Competency Verification
Penalty
Summary
The facility failed to provide adequate nutritional support and timely identification of severe weight loss for two residents. One resident, admitted with communication and anoxic damage, experienced a 6.7% weight loss over six weeks. Despite observations of the resident struggling to eat due to uncontrollable shaking, no nutritional supplements were ordered, and the resident was left unsupervised during meals. The Registered Dietitian was aware of the weight loss but did not implement weekly weight monitoring or additional nutritional interventions, leading to a severe weight loss of 11.5% in less than two months. Another resident experienced a 9.8% weight loss in one month, with an overall 14% loss over three months. The resident's meal intake was less than 50% over the past 30 days, and although interventions such as fortified food and house shakes were initiated, there was a delay in implementing these measures. The Registered Dietitian failed to place an order for the house shake immediately, resulting in a lack of timely nutritional support. Additionally, the facility did not ensure the competency of a resident performing self-care for a tracheostomy. The resident was observed changing her inner cannula without recent competency verification, as the last documented competency was over a year ago. The facility could not locate the competency checklist, and the resident continued to change her inner cannula more frequently than recommended, without proper oversight or documentation in the electronic health record.
Plan Of Correction
Actions Taken: 1) Resident #52 was evaluated by the Registered Dietitian on and additional nutritional interventions were implemented. A comprehensive nutritional assessment was completed for Resident #52 on and the resident now attends the dining room for his meals for oversight and assistance as needed. On resident #52 was placed on an appetite stimulant. Resident #52 was placed on weekly and is currently receiving Occupational and Speech therapies. The Resident's responsible party has been updated. Resident #56 was evaluated by the Registered Dietitian on and additional nutritional interventions were implemented. A comprehensive nutritional assessment was completed for Resident #56 on the resident was seen by the Speech Pathologist and her diet was downgraded to Puree and on the resident was placed on an appetite stimulant. Resident #56 is currently receiving Occupational and Speech therapies. The Resident's responsible party has been updated. Others Identified: 2) Full house audit completed between by the Registered Dietitian/Designee to identify residents that may have been affected due to delayed loss intervention or missing a nutritional intervention in the electronic medical record or ticket system recommended by the Registered Dietitian. Additional documentation recommended from the full house audit was completed by facility Registered Dietitian by Regional Dietitian completed a full house audit between to ensure residents have been per protocol and monitored appropriately to identify severe loss. Any concerns identified were immediately addressed. Measures Taken: 3) Regional Dietitian in-serviced the Registered Dietitian on regarding timely nutrition interventions with a focus on residents with loss as well as ensuring nutritional interventions are placed in electronic medical record and ticket system timely as applicable. Nursing staff were re-educated to refer to resident Kardex in reference to the amount of assistance required with meals initiated on by Ellie Schutt, LNHA/Designee. Ongoing Monitoring: 4) The Registered Dietitian/Designee will conduct an audit of 10 residents on each unit weekly to ensure the residents with loss have timely documentation with nutritional interventions and verify that the nutritional interventions are placed in the EMR and the ticketed system timely weekly x 4 weeks, and then every 2 weeks x 2 months. Findings of the audits will be reviewed in the QAPI Meetings to ensure substantial compliance. The QAPI committee is responsible for the ongoing compliance.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to treat a resident in a dignified manner and provide personal privacy. Resident #108, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was observed on two occasions lying on her bed with the door open, uncovered, and without underwear. The resident was seen playing with her Foley catheter during one of these observations. The resident's Minimum Data Set (MDS) assessment indicated a Brief Interview of Mental Status (BIMS) score of 99, suggesting an inability to complete the interview, and a dependency on assistance for movement in bed. A Certified Nursing Assistant (CNA) interviewed acknowledged the importance of maintaining dignity and privacy, stating that residents should not be exposed and that doors should be closed during care or changing, especially for residents who are not fully conscious.
Plan Of Correction
Boca Circle Rehabilitation Center failed to treat the resident in a dignified manner and provide personal privacy. Actions Taken: 1) On resident #108 was provided with personal privacy during personal care by the C.N.A. Education was initiated on with staff regarding providing dignity and privacy for residents during personal cares. Others Identified: 2) Full house audit was conducted by the DON/Designee on to ensure privacy was being provided during personal care. No other concerns were noted. Measures Taken: 3) Nursing Staff were re-educated on regarding regarding resident rights, dignity and privacy during personal cares and that privacy curtains must be pulled and the door closed so residents are treated in a dignified manner. New staff will receive this education during general orientation. Ongoing Monitoring: 4) Unit Manager or designee will audit personal care and resident right to privacy during personal cares weekly x 4 weeks and then every 2 weeks x 2 months. Audit results will be reviewed in Center QAPI meeting monthly until substantial compliance has been met.
Failure to Appoint Guardian for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to appoint a guardian in a timely manner for a resident with severe cognitive impairment. The resident, who was admitted from another nursing facility, had a Brief Interview for Mental Status (BIMS) score of 2, indicating severe cognitive impairment. The resident's family had not been involved for years, and the only listed representative, a cousin, had requested to be removed from the contact list. Despite the resident's need for a legal representative, the facility had not successfully appointed a guardian. Interviews with the Social Service Director (SSD) and the Administrator revealed that the facility had been attempting to address the guardianship issue since early 2024, but progress was hindered by difficulties in finding an attorney. The SSD admitted that the facility had been working on the issue longer than initially thought, but no paperwork was found to support this. The Administrator was unaware of the resident's need for guardianship until the day of the interview and stated that the facility lacked a policy on guardianship. The process of obtaining guardianship typically takes 6 to 9 months, depending on the court system.
Plan Of Correction
Boca Circle Rehabilitation Center failed to appoint a guardian in a timely manner for 1 of 1 resident sampled for guardianship. Actions Taken: 1) Resident #56 continues to reside at the facility. On Center SSD obtained a proxy for resident #56. SSD was re-educated by Ellie Schutt, LNHA on to ensure of a guardian is done timely. Others Identified: 2) On a residents records were audited to ensure that residents with a less than 12 had a designated representative or legal surrogate. Any concerns identified were immediately addressed. Measures Taken: 3) Social Services staff and members if the Interdisciplinary team were re-educated on obtaining guardianship or a proxy timely on residents who are unable to direct their care by Ellie Schutt, LNHA. Newly hired Social Service staff and nursing management will receive this education during general orientation. Ongoing Monitoring: 4) Social Services or designee will audit residents with a of less than 12 to ensure that residents identified have a guardian or a proxy in place to ensure that residents have the right to designate a representative upon admission, weekly x 4 weeks, and then every 2 weeks x 2 months. Audit results will be reviewed in Center QAPI meeting monthly to ensure compliance has been met.
Failure to Complete Level 2 PASARR for Resident
Penalty
Summary
The facility failed to complete a Level 2 Preadmission Screening and Resident Review Process (PASARR) for a resident who was sampled for PASARR. The resident was admitted to the facility with diagnoses including Paralytic Syndrome, Bipolar Disorder, Current Episode Depressed, and Peripheral Vascular Disease. A Level 1 PASARR was conducted at the hospital prior to the resident's admission, indicating a hospital discharge exemption with an expectation of less than 30 days of nursing facility services. However, the resident's stay exceeded this period, necessitating a Level 2 PASARR, which was not completed. During a review of the Electronic Health Record (EHR), it was found that the Level 2 PASARR was missing. The Social Service Director (SSD) confirmed the absence of the Level 2 PASARR and acknowledged that it should have been completed based on the Level 1 PASARR findings. The SSD was unable to locate the Level 2 PASARR in the resident's records, indicating a lapse in the facility's compliance with the PASARR process requirements.
Plan Of Correction
The facility failed to complete a Level 2 Pre admission Screening and Resident Review Process (PASARR) for Resident #50. **Actions Taken:** 1) The Center Social Service Director submitted information for Preadmission Screening and Resident Review (PASARR) for a re-evaluation for resident #50. New PASARR for resident #50 was received on and a Level 2 was obtained. **Others Identified:** 2) A full house audit of current residents' Preadmission Screening and Resident Review (PASARR) was conducted to ensure that any resident with a new mental health diagnosis(s) had a PASARR evaluation completed and any mental health diagnosis(s) were identified on the current PASARR screen. Those residents identified that do not have an accurate PASARR evaluation on file will be resubmitted for a new PASARR screening no later than. Social Service staff and Nursing management are scheduled to attend Kepro training on PASARRs. **Measures Taken:** 3) The Administrator provided education to the Social Worker(s), Nursing management, and Admissions team on the requirements of the Preadmission Screening and Resident Review (PASARR) processing for mental and individuals with. **Ongoing Monitoring:** 4) The Social Worker(s) and Admission Director will audit each resident's PASARR Screen at the time of admission, during monthly Behavioral meetings, and quarterly thereafter to ensure accuracy. The Social Worker will report on the findings of the audits in the QAPI Meetings to ensure substantial compliance. The QAPI committee is responsible for the ongoing compliance.
Failure to Assist Residents During Dining
Penalty
Summary
The facility failed to provide necessary assistance during dining for two residents, specifically Resident #71 and Resident #52, who were reviewed for activities of daily living (ADLs). Resident #71 was admitted with diagnoses including Atherosclerotic Heart Disease and Neuromuscular Dysfunction of the Bladder. The Minimum Data Set (MDS) assessment indicated that Resident #71 had a moderately impaired mental status and required supervision or touching assistance during dining. However, observations on two separate occasions revealed that Resident #71 was left unattended with her meal trays for extended periods, without any staff present to assist or encourage her to eat. Interviews with facility staff revealed inconsistencies in understanding the level of assistance required by Resident #71. A Certified Nurse Assistant (CNA) acknowledged that the resident sometimes needed to be fed and encouraged to eat, while a Registered Nurse (RN) believed the resident could eat without staff presence. The MDS Coordinators clarified that supervision or touching assistance meant the resident needed help with tray setup and encouragement during meals. Despite this, the CNAs, who were responsible for dining assistance, were not consistently present to provide the necessary support, leading to the deficiency in care.
Plan Of Correction
The facility failed to provide assistance during dining. **Actions Taken:** 1) Resident #71 remains in the facility in stable condition. A screen was conducted on [date]. The resident now attends the dining room for her meals for oversight and assistance as needed. Staff E, CNA and staff F, RN were re-educated to refer to resident Kardex in reference to the amount of assistance required with meals on [date] by Aristine Recht, Assistant Director of Nursing. **Others Identified:** 2) A full house audit was conducted by the Director of Nursing/Designee on [date] to ensure residents were provided assistance during dining. Any concerns identified were immediately addressed. **Measures Taken:** 3) Nursing staff were re-educated on providing assistance to residents during dining as per resident Kardex on [date] by DON/Designee. Newly hired nursing staff will receive this education during general orientation. **Ongoing Monitoring:** 4) The Director of Nursing/Designee will conduct an audit of 10 residents on each unit weekly to ensure the residents receive assistance during dining weekly for 4 weeks, and then every 2 weeks for 2 months. Findings of the audits will be reviewed in the QAPI Meetings to ensure substantial compliance. The QAPI committee is responsible for the ongoing compliance.
Failure to Ensure Resident Competency in Respiratory Care
Penalty
Summary
The facility failed to ensure the competency of a resident in performing respiratory care, specifically in changing her tracheostomy inner cannula. Resident #58, who was admitted with diagnoses including Respiratory Failure and Tracheostomy Status, was observed to change her own inner cannula without recent documented competency verification. The resident, who is cognitively intact, reported changing her inner cannula up to three times a day, despite instructions to change it only twice daily. The facility's respiratory therapist confirmed that the resident's competency was last assessed over a year ago, and no current documentation of competency was found in the Electronic Health Record (EHR). The surveyor's investigation revealed that the facility could not locate the competency documentation, as it was reportedly on paper with a previous company. The Regional Nurse Consultant acknowledged the absence of the competency record in the EHR. Additionally, the resident's EHR indicated that she was running out of inner cannulas due to frequent changes, and the facility had doubled her order to prevent shortages. The resident was re-educated on the inner cannula change process only after the surveyor's intervention.
Plan Of Correction
Boca Circle Rehabilitation Center failed to ensure the residents competency when performing care. Actions Taken: 1) Resident #58 was evaluated by the on & and competency and education was completed and uploaded into the electronic medical record. Staff P. was provided education on by the Regional on ensuring documented education and competency is documented for residents that perform self-care. Others Identified: 2) Full house was conducted by the DON/Designee on to ensure residents with that perform their own care have a competency completed. No concerns noted. Measures Taken: 3) Nursing Staff were in serviced on ensuring residents with who perform their own care are assessed for competency starting on by DON/Designee. Newly hired staff and nursing staff will receive this education during general orientation. Ongoing Monitoring: 4) The Director of Nursing/Designee will conduct weekly audits to verify that residents with that care have perform their own care, have a competency completed weekly x 4 weeks, and then every 2 weeks x 2 months. Audit results will be reviewed in Center QAPI meeting until substantial compliance is met.
Failure to Monitor Psychotropic Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to adequately monitor the behaviors and side effects of a resident on psychotropic medications, leading to a deficiency in the resident's care. The resident, who was admitted with anxiety disorder and major depressive disorder, was prescribed Lorazepam for anxiety and Paroxetine for depression. The care plan required the facility to administer these medications as ordered and to monitor and document any side effects and the occurrence of target behavior symptoms per facility protocol. However, a review of the Medication Administration Record for December 2024 and January 2025 revealed that there was no documentation of behavior or side effect monitoring for the resident. During an interview, a Licensed Practical Nurse stated that residents on such medications are monitored for behaviors and side effects, and this information is documented in the electronic Medication Administration Record. However, when asked to provide documentation for this resident, the nurse was unable to do so. The facility's Administrator was informed of these findings, indicating a lapse in the facility's adherence to its own protocols for monitoring residents on psychotropic medications.
Plan Of Correction
Boca Circle Rehabilitation Center failed to monitor behaviors and side effects of medication. Actions Taken: 1) Resident #52's medication administration record has been updated to include behavior and side effect monitoring was implemented on Stafi L, LPN, was re-educated by the DON/Designee on to ensure medication administration records have behavior and side effect monitoring present were indicated. Others Identified: 2) A full house audit was conducted by the Director of Nursing/Designee on to ensure behavior and side effect monitoring is in place for residents receiving medications. Behavior and side effect monitoring was implemented as indicated. Measures Taken: 3) Licensed Nurses were re-educated on the components of this regulation with an emphasis on ensuring the residents on medications have behavior and side effect monitoring in place on the medication administration record. Newly hired licensed staff will receive this education during general orientation. Ongoing Monitoring: 4) The Director of Nursing/Designee will conduct weekly audits of 10 residents on each unit to verify that residents on medications have behavior and side effect monitoring in on the medication administration record weekly x 4 weeks, and then every 2 weeks x 2 months. Audit results will be reviewed in Center QAPI meeting until substantial compliance has been met.
Inadequate Pureed Diet Consistency for Residents
Penalty
Summary
The facility failed to provide the correct diet consistency for residents on a pureed diet, as observed in three residents. The pureed Chicken Pot Pie served to these residents was lumpy, and the green beans shell were easily identifiable, which did not meet the required pureed consistency. This inconsistency was observed during meal times in both the main dining room and individual resident rooms. The residents involved had various medical conditions, including Atrial Fibrillation, Gastro-Esophageal Reflux Disease, Combined Systolic and Diastolic Heart Failure, Muscle Wasting and Atrophy, and Hemiplegia following a Cerebral Infarction. All three residents were unable to conduct interviews due to their mental status, as indicated by their Brief Interview of Mental Status (BIMS) scores. The Speech Therapist at the facility confirmed that pureed food should be blended into a uniform consistency, but admitted that no training had been conducted with the kitchen staff since her employment began in July. The District Manager stated that she routinely checks the pureed food consistency before it is served, but the deficiency was still present. The facility's policy referenced the National Dysphagia Diet guidelines, which require a homogenous, pudding-like consistency for pureed foods, a standard that was not met in these instances.
Plan Of Correction
Boca Circle Rehabilitation Center failed to provide the correct diet consistency for the Pureed diet. **Actions Taken:** 1) Resident #35 & #108 remain in the facility in stable condition. Resident #102 no longer resides in the facility. **Others Identified:** 2) Full house was conducted by the Dietary Manager/Designee to ensure the residents diet consistencies were correct. Any concerns identified were immediately addressed. **Measures Taken:** 3) Dietary Staff were in serviced on ensuring the residents diet consistency is accurate by Certified Dietary Manager. Nursing staff were re-educated to monitor diet consistency during meal tray check/pass. Newly hired dietary staff and nursing staff will receive this education during general orientation. **Ongoing Monitoring:** 4) The Dietary Manager/Designee will conduct daily audits 5X/week to verify that residents diet consistencies are correct x 4 weeks, and then 2X/week for 2 weeks then weekly for 2 months. Audit results will be reviewed in Center QAPI meeting until substantial compliance has been met.
Failure to Meet Residents' Dietary Preferences and Needs
Penalty
Summary
The facility failed to provide meals that met the dietary preferences, allergies, and intolerances of four residents during dining observations. Resident #56, who has severe cognitive impairment, did not receive the fortified mashed potatoes listed on their meal ticket. Resident #15, with no cognitive impairment, was missing ice cream from their meal tray. Resident #118, also with no cognitive impairment, expressed frustration over consistently receiving green vegetables, which they had explicitly stated they disliked. Resident #368, newly admitted and without a completed Minimum Data Set, reported that their food preferences were not considered, receiving items they do not consume, and described the food as inedible and served cold. The facility's meal distribution process was observed to have multiple checkpoints intended to ensure meal tickets match the trays, involving aides and nurses. However, during observations, it was noted that the Licensed Practical Nurses (LPNs) distributing the trays did not uncover the plates to verify the food consistency against the meal tickets. Despite the District Manager's assertion of a thorough checking process, discrepancies in meal delivery were evident, as seen in the cases of the residents mentioned. Interviews with staff revealed inconsistencies in the meal distribution process. Staff B, an LPN with over 11 years of experience, claimed to check the meal tickets and uncover plates to verify consistency, yet observations contradicted this. Similarly, Staff A, another LPN, admitted to not uncovering plates during distribution, relying on Certified Nursing Assistants to report inconsistencies. These lapses in procedure contributed to the failure in meeting residents' dietary needs and preferences, as documented in the survey findings.
Plan Of Correction
Boca Circle Rehabilitation Center failed to provide food that meets residents' preferences and intolerances. **Actions Taken:** 1) Resident #56 was seen by the Registered Dietician on and remains in the facility in stable condition. Resident #15 was seen by the Registered Dietician on and remains in the facility in stable condition. Resident #118 remains in the facility in stable condition. Resident was seen by the Registered Dietician on and food preferences have been updated. Resident #368 remains in the facility in stable condition. Resident was seen by the Registered Dietician on and food preferences have been updated. Staff A, LPN was reeducated on verifying plated food matches residents' meal ticket on by Ellie Schutt, LNHA. Staff B, LPN was reeducated on verifying plated food matches residents' meal ticket on by Ellie Schutt, LNHA. Staff D, LPN was reeducated on verifying plated food matches residents' meal ticket on by Ellie Schutt, LNHA. **Others Identified:** 2) A facility audit was conducted by the Dietary Manager/Designee on to ensure provision of food to meet residents' preferences and intolerances. Residents' dietary preferences were updated as indicated. **Measures Taken:** 3) Dietary Staff were in-serviced on ensuring the residents' diet preferences are honored including condiments on by CDM. Education for Licensed Nurses and CNAs was initiated on regarding checking the meal tickets and meal tray for correct consistency by DON/Designee. Newly hired dietary and nursing staff will receive this education during general orientation. **Ongoing Monitoring:** 4) Dietary Manager/Designee will conduct audits 5x/week to verify that residents' dietary preferences are correct and Licensed Nurses are checking meal trays for correct consistency x 4 weeks, and then every week x 4 weeks, followed by weekly x 1 month. Audit results will be reviewed in Center QAPI meeting until substantial compliance has been met.
Meal Delivery Delays in LTC Facility
Penalty
Summary
The facility failed to adhere to the posted schedule for meal tray deliveries during two separate observations. On the first observation, lunch trays were significantly delayed across various dining areas and halls, with actual delivery times ranging from 12:52 PM to 1:43 PM, despite scheduled times between 11:30 AM and 12:10 PM. A second observation revealed similar delays, with trays arriving between 11:50 AM and 12:25 PM, contrary to the scheduled times of 11:30 AM to 12:00 PM. These discrepancies were confirmed through interviews with residents who consistently reported late meal deliveries. Two residents, both cognitively intact with a Brief Interview of Mental Status Score of 15, expressed concerns about the late meal deliveries. One resident, diagnosed with Parkinson's and muscle weakness, reported that lunch meals often arrived between 12:30 PM and 1:00 PM, sometimes even later. Another resident, with diagnoses of muscle weakness and difficulty walking, stated that it was common for trays to arrive around 1:30 PM on their unit. The kitchen District Manager acknowledged that meal timing changes were made for breakfast and dinner but inadvertently omitted lunch, contributing to the delays.
Plan Of Correction
Boca Circle Rehabilitation Center failed to follow their posted scheduled meal time for tray delivery. **Actions Taken:** 1) Residents residing in the facility have the potential to be affected by the alleged deficient practice. The facility has reviewed and readjusted mealtimes. Updated postings have been made available to residents and visitors. A resident council meeting was held on the updated posting of mealtimes. **Others Identified:** 2) A facility audit was conducted by the Certified Dietary Manager to ensure the residents' meals were delivered timely. **Measures Taken:** 3) Dietary Staff were in-serviced by the CDM on the components of this regulation with an emphasis on ensuring the meals are delivered as per the posted mealtimes. Newly hired dietary staff will receive this education during general orientation. **Ongoing Monitoring:** 4) The Dietary Manager/Designee will conduct audits to verify that the meal delivery follows the posted meal delivery times 3x weekly for 4 weeks, and then weekly for 4 weeks, and every 2 weeks for 1 month. Audit results will be reviewed in the Center QAPI meeting until substantial compliance has been met.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure the proper disposal of garbage and refuse in a sanitary manner, as observed during a survey. The facility's policy, dated August 2017, mandates that all garbage and refuse be collected and disposed of safely and efficiently, with coordination between the Dining Service Director and the Director of Maintenance to maintain cleanliness around the exterior dumpster area. However, during an observation, a large blue metal construction dumpster was found to contain garbage bags and multiple food boxes, emitting a foul smell and attracting insects. The maintenance director acknowledged that he had repeatedly informed the kitchen staff that the construction dumpster was designated solely for construction waste and not for kitchen garbage, which could attract rodents and insects. Despite his efforts, the issue persisted, and he noted that he was not present at the facility 24/7 to enforce compliance. The facility's Administrator was informed of these findings during an interview.
Plan Of Correction
Boca Circle Rehabilitation Center failed to ensure disposal of garbage and refuse in a sanitary manner. Actions Taken: 1) On the Director of Dietary corrected the deficient practice to ensure disposal of garbage and refuse was done in a sanitary manner. Others Identified: 2) The construction dumpster is set to be removed on . The garbage and refuse identified were disposed of in a sanitary manner on by the CDM. Measures Taken: 3) Dietary and Maintenance staff were re-educated on by Ellie Schutt, LNHA on ensuring disposal of garbage and refuse in a sanitary manner. Newly hired dietary and maintenance staff will receive this education during general orientation. Ongoing Monitoring: 4) The Dietary Manager/Designee will conduct audits 3x weekly to verify appropriate disposal of garbage and refuse x 4 weeks, then weekly x 4 weeks, and then every 2 weeks x 1 month. Audit results will be reviewed in Center QAPI meeting until substantial compliance has been met.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during medication administration and respiratory treatments for two residents. One resident, who was cognitively intact and diagnosed with Chronic Obstructive Pulmonary Disease, was observed receiving respiratory treatment via nebulizer without the staff performing hand hygiene before or after handling the nebulizer mask and medications. The staff member acknowledged the lapse in hand hygiene during the medication administration process. Another resident, with diagnoses including Cerebral Infarction and Major Depressive Disorder, was observed receiving medication from a nurse who directly touched oral capsules and pills with gloved hands instead of using a cap to transfer them to a medication cup. The nurse acknowledged the improper handling of medications, and the Director of Nursing confirmed that the medications should not have been touched directly with gloved hands. Additionally, the facility did not follow sanitary procedures during the disconnection of dialysis treatment for a resident with End Stage Renal Disease. The staff member performing the disconnection touched a hand sanitizing bottle and then proceeded to disconnect the dialysis access site without changing gloves or performing hand hygiene again. This failure to maintain proper infection control practices was acknowledged by the staff involved.
Plan Of Correction
Boca Circle Rehabilitation Center failed to properly follow hygiene protocol and handle medications in a sanitary manner. Disconnecting treatment in an unsanitary manner. Actions Taken: 1) Residents #90 no longer resides at the center. Resident #101 was seen by MD on and remains at baseline without signs or symptoms of. Resident #79 was seen by MD on and remains at baseline without signs or symptoms of. Staff C, LPN/Unit manager, was reeducated on by hygiene protocol during treatments. Staff D, RN, was reeducated on by DON/Designee on handling medications in a sanitary manner while dispensing medications. Staff M, patient care tech, was reeducated on by Karen Castelloni, to follow sanitary procedures for disconnecting treatment. Others Identified: 2) A full house audit of nurses doing medication administration and performing hygiene was initiated by the DON/Designee on. Any concerns identified were immediately addressed. DON/Designee conducted an audit on of the treatment being disconnected. No concerns noted. Measures Taken: 3) License Nurses were reeducated on by DON/Designee on the components of this regulation with an emphasis on appropriate and frequent hygiene during medication administration, handling medications in a sanitary manner, and proper hygiene protocol during treatments. Staff were reeducated on disconnecting the treatment in a sanitary manner by Karen Castelloni. Newly hired licensed nurses and staff will receive this education during general orientation. Ongoing Monitoring: 4) The Director of Nursing/Designee will conduct audits to verify appropriate hygiene during medication administration, handling medications in a sanitary manner, and proper hygiene protocol during treatments and staff disconnecting the treatment in a sanitary manner 3x weekly times x 4 weeks, and then weekly x 4 weeks and then every 2 weeks x 1 month. Audit results will be reviewed in Center QAPI meeting until substantial compliance has been met. F 880
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to treat a resident with dignity and provide personal privacy, as observed during the survey process. The resident, who was admitted with multiple diagnoses and was fully dependent on assistance for mobility, was seen lying on her bed without underwear or a blanket, with the door open, on two separate occasions. During an interview, a Certified Nurse Assistant (CNA) acknowledged the importance of maintaining residents' dignity and privacy, stating that doors should be closed when providing care and that residents should always wear underwear, especially if they are not fully clothed.
Plan Of Correction
Boca Circle Rehabilitation Center failed to treat the resident in a dignified manner and provide personal privacy. **Actions Taken:** 1) On resident #108 was provided with personal privacy during personal care by the C.N.A. Education was initiated on with staff regarding providing dignity and privacy for residents during personal cares. **Others Identified:** 2) Full house audit was conducted by the DON/Designee on to ensure privacy was being provided during personal care. No other concerns were noted. **Measures Taken:** 3) Nursing Staff were re-educated on regarding regarding resident rights, dignity and privacy during personal cares and that privacy curtains must be pulled and the door closed so residents are treated in a dignified manner. New staff will receive this education during general orientation. **Ongoing Monitoring:** 4) Unit Manager or designee will audit personal care and resident right to privacy during personal cares weekly x 4 weeks, and then every 2 weeks x 2 months. Audit results will be reviewed in Center QAPI meeting monthly until substantial compliance has been met.
Deficiency in Commercial Cooking Hood Suppression System
Penalty
Summary
The facility failed to maintain its commercial cooking facility in accordance with NFPA 101 standards. During a fire safety tour, it was observed that the seams of the kitchen's commercial cooking hood suppression system were not sealed or made greasetight. This deficiency was identified during an inspection conducted on February 4, 2025, at 11:09 AM, with the Maintenance Director present. The Maintenance Director acknowledged the findings during an interview conducted concurrently with the observations. The issue was further reviewed with the Administrator, the Regional Maintenance Director, and the Maintenance Director during the exit conference on the same day at 2:40 PM. The report cites specific sections of NFPA 96 and NFPA 101 that were not adhered to, indicating a failure to comply with the required fire safety standards for commercial cooking operations.
Plan Of Correction
Corrective Actions The facility's kitchen hood seams were sealed to ensure that the kitchen hood was grease tight on 2/5/2025. Identification of Others Potentially Affected The facility only has one kitchen hood, so no further evaluations are needed. Systemic Changes The Maintenance Director, or designee, will continue to perform documented monthly inspections of the facility's kitchen hood to ensure the kitchen hood seams remain sealed and grease tight on an ongoing basis as part of the facility's life safety program. Quality Assurance Results of the monthly kitchen hood inspections will be presented at the monthly QA meetings for 3 months. If substantial compliance is not met after 3 months, results of the ongoing monthly inspections will be brought to QA meetings until substantial compliance is met.
Failure to Maintain Essential Electrical System
Penalty
Summary
The facility failed to maintain and test their Essential Electrical System in accordance with NFPA 99 standards. During a record review conducted on February 4, 2025, it was identified that there was no documentation available for weekly voltage checks for two generator batteries. Additionally, there was no documentation for monthly sealed battery conductance tests for these same batteries. This lack of documentation indicates that the facility did not perform the required maintenance and testing procedures for their generator batteries. The Regional Director of Maintenance was present during the record review and acknowledged the findings. The absence of these critical maintenance records suggests a failure to adhere to the necessary protocols for ensuring the reliability and safety of the facility's emergency power systems. This deficiency was noted as a violation of the NFPA 99 and NFPA 110 standards, which are essential for maintaining the operational readiness of the facility's electrical systems.
Plan Of Correction
Corrective Actions The following actions occurred on 2/17/2025: A. The weekly generator inspection form was updated to include a battery voltage reading for both generator batteries. B. The monthly generator inspection form was updated to include a battery conductance reading for both generator batteries. Identification of Others Potentially Affected Both facility generator batteries were accounted for, so no further evaluation was needed. Systemic Changes The Maintenance Director, or designee, will continue to perform documented weekly generator inspections to include documentation of the battery voltage, and monthly generator testing to include documentation of the battery conductance testing, on an ongoing basis as part of the facility's life safety program. Quality Assurance Results of the weekly inspections and monthly battery testing will be presented at the monthly QA meetings for 3 months. If substantial compliance is not met after 3 months, monthly inspections will continue, and results will be brought to QA meetings until substantial compliance is met.
Non-compliance with Egress Door Standards
Penalty
Summary
The facility failed to maintain egress doors equipped with delayed egress locking arrangements in accordance with NFPA 101 standards. During a fire safety tour, it was observed that several egress doors were not compliant. Specifically, the 500 Hallway Lobby double exit doors and the Main Lobby double interior egress doors were missing the required signage on both leaves. Additionally, the Main Lobby double-interior-egress doors were missing signage from the left leaf. Furthermore, the Therapy Lobby double exit doors, which were equipped with 30-second delayed egress locks, failed to open when tested. These observations were made in the presence of the Maintenance Director, who acknowledged the findings. The issues were subsequently reviewed with the Administrator, the Regional Maintenance Director, and the Maintenance Director during an exit conference.
Plan Of Correction
Corrective Actions 1. The following egress doors had signage added to indicate the presence of a 30 second delayed egress locking arrangement on 2/5/2025. A. 500 Hallway Lobby double exit doors. (30 second Delay Signage) B. Main Lobby double interior egress doors. (15 second Delay Signage) C. Main Lobby double interior egress doors, left leaf. (15 second Delay Signage) 2. The Therapy Lobby double exit doors were evaluated and made to function properly when the delayed egress locking arrangement was initiated on 2/5/2025. Identification of Others Potentially Affected The Maintenance Director, or designee, performed a facility-wide assessment of the other egress doors to ensure the following: 1. Doors with a delayed egress locking arrangement had the correct signage. 2. Doors with a delayed egress locking arrangement functioned properly. Systemic Changes The Maintenance Director, or designee, will continue to perform documented monthly inspections of all egress doors with a delayed egress locking arrangement to ensure the correct signage is in place, and to ensure the doors properly function, on an ongoing basis as part of the facility's life safety program. Quality Assurance Results of the monthly egress door inspections will be presented at the monthly QA meetings for 3 months. If substantial compliance is not met after 3 months, results of the ongoing monthly inspections will be brought to QA meetings until substantial compliance is met.
Fire/Smoke Barrier Integrity Compromised
Penalty
Summary
The facility failed to maintain the integrity of their fire/smoke barrier construction as required by NFPA 101 standards. During a fire safety tour conducted on February 4, 2025, with the Regional Maintenance Director and the Maintenance Director, it was observed that there were penetrations through both sides of the 1-hour smoke wall in two different hallways. Specifically, at 11:58 AM, a penetration was found above the ceiling of the double fire-rated doors in the 100 Hallway. Similarly, at 12:10 PM, another penetration was identified above the ceiling of the double smoke doors in the 300 Hallway. These penetrations compromise the fire resistance rating of the smoke barriers, which are crucial for restricting the movement of fire and smoke within the facility. The Maintenance Director acknowledged these findings during the observations. The issue was further discussed with the Administrator, the Regional Maintenance Director, and the Maintenance Director during the exit conference held on the same day at 2:40 PM. The report emphasizes that these examples are not exhaustive, suggesting that a thorough inspection of each barrier should be conducted to ensure all penetrations are identified and properly sealed. The penetrations in fire-rated barriers must be sealed with a UL-listed approved system to restore the wall, ceiling, or floor to its original fire or smoke-rated integrity, ensuring the safety of the facility's occupants in the event of a fire emergency.
Plan Of Correction
Corrective Actions The following locations had penetrations sealed with fire stopping on 2/5/2025: A. 100 Hallway smoke barrier. B. 300 Hallway smoke barrier. Identification of Others Potentially Affected The Maintenance Director, or designee, performed a facility-wide assessment of the other fire and smoke barriers to ensure all penetrations are sealed with fire stopping. Systemic Changes The Maintenance Director, or designee, will perform monthly inspections X 3 months of the fire and smoke barriers to ensure all penetrations are sealed with fire stopping. Inspections will continue semi-annually thereafter on an ongoing basis as part of the facility's life safety program. Quality Assurance Results of the monthly fire and smoke barrier inspections will be presented at the monthly QA meetings X 3 months. If substantial compliance is not met after 3 months, monthly inspections will continue, and results will be brought to QA meetings until substantial compliance is met.
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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