Community Convalescent Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Plant City, Florida.
- Location
- 2202 W Oak Ave, Plant City, Florida 33563
- CMS Provider Number
- 105029
- Inspections on file
- 21
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Community Convalescent Center during CMS and state inspections, most recent first.
A resident with vertigo and multiple comorbidities, including Type 2 DM with neuropathy, heart failure, and CKD stage 3A, missed a scheduled ENT appointment when transportation arrived but the resident had not been informed of the appointment and was not prepared to go. The resident reported being told the appointment would be rescheduled, but this did not occur. An RN confirmed the appointment had to be rescheduled and that Medical Records staff handle such scheduling, while the CNA/Medical Records staff stated she was not aware the appointment needed rescheduling and later did not complete the task due to lack of time. The DON stated that appointments are expected to be followed up on timely, and the facility’s Transportation Services policy requires coordination with the Medical Records designee and timely rescheduling, which did not occur in this instance.
The facility did not ensure adequate kitchen staffing on several days, resulting in only one cook and one dietary aide present for meal shifts and requiring CNAs to be pulled from their regular assignments to assist in the kitchen. This led to delays in meal service, use of disposable serving ware, and missed resident care tasks such as showers, as CNAs' floor assignments were not always covered.
Surveyors identified extensive deficiencies in food storage, labeling, and sanitation, with numerous undated and unlabeled food items, spoiled produce, and improper storage of raw meats. Dietary staff failed to follow hand hygiene and glove use protocols, moving between tasks without washing hands or changing gloves. Cleaning and temperature logs were incomplete or missing, and the kitchen environment was unsanitary, with evidence of bio growth and insect activity. These findings reflect a failure to maintain a clean, safe, and sanitary environment in accordance with professional standards.
The facility did not update its facility-wide assessment to include emergency plans, required staff competencies for residents with different acuity levels, or specific staffing needs for each shift. Staff interviews revealed a lack of awareness and understanding of the assessment process, and the assessment itself was missing critical sections as identified during record review.
Surveyors identified multiple infection control deficiencies, including unattended open meal carts, failure to provide hand hygiene to residents before meals, unclean laundry areas with soiled linens and dust-covered equipment, an overfilled sharps container with syringes protruding above the fill line, and a dialysis patient with a red-stained towel and dirty fingernails. Staff interviews confirmed inconsistent cleaning and infection control practices.
The facility did not complete required antibiotic use monitoring for four months, with missing or incomplete surveillance forms and infection mapping. The DON, acting as Infection Preventionist, was unable to locate necessary documentation and had not educated nursing staff on proper form completion or infection control. Required audits and Quality Assurance reviews of antibiotic use were not documented as per policy.
Surveyors found multiple rooms with holes in walls, peeling ceilings, unpainted surfaces, missing baseboards, and bio growth in two wings. The Maintenance Director acknowledged responsibility but had not completed a comprehensive review, and only one room was listed in the work order system despite numerous deficiencies observed. Facility policies and job descriptions required proper maintenance, but these standards were not met in the affected areas.
The facility did not provide scheduled activities for residents on several observed days due to the absence of the Activity Director and lack of coverage, despite having an activity calendar and a policy requiring activities to meet residents' needs. Interviews with the DON and NHA confirmed that no one was available to conduct activities as planned.
Several residents were not offered the Influenza or Pneumococcal vaccines as required, and for those who were, there was no documentation of vaccine administration. The DON, acting as Infection Preventionist, had not checked immunization status or provided required education, and facility policy steps for consent, orders, and documentation were not consistently followed.
The facility did not ensure that three residents were properly offered and documented for the COVID-19 vaccine, with one not being offered the vaccine and two lacking documentation of administration after being offered. The DON, acting as Infection Preventionist, had not checked immunization status or provided required education, contrary to facility policy.
A resident with chronic health conditions reported missing and damaged clothing, and multiple residents expressed concerns about slow grievance resolution, especially regarding laundry. The facility did not provide evidence that grievances were resolved or that required follow-up actions were completed, and documentation was incomplete, contrary to facility policy.
The facility failed to complete a required Level II PASRR for a resident with multiple mental health diagnoses and did not ensure the accuracy of a Level I PASRR for another resident by omitting updated diagnoses. These deficiencies occurred despite facility policy requiring comprehensive preadmission screening and regular review of PASRR documentation.
Two residents were found with long, discolored fingernails and reported that staff had not offered or provided regular nail care, despite care plans instructing nail checks and trimming on bath days. Documentation showed inconsistent provision of nail care, incomplete shower logs, and lack of proper documentation for refusals. Staff interviews confirmed that nail care was not always performed, especially when CNAs were assigned to other duties, and the facility did not have a specific ADL policy.
A dependent resident with multiple medical conditions was not assisted out of bed by staff, despite her care plan requiring staff assistance for transfers. The resident reported not receiving help to use the toilet or attend activities, and was observed lying in bed on several occasions. Staff interviews confirmed that assistance was only provided upon resident request, which was inconsistent with facility policy and the resident's care plan.
A resident with multiple chronic conditions and intact cognition was observed to have severely overgrown and malformed toenails. Although the resident expressed a need for podiatry care, staff had not ensured timely assessment or referral to podiatry services. Documentation did not specify whether toenail care was provided, and facility leadership was unclear about the referral process and podiatry visit frequency.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents, resulting in an unsafe environment.
Two residents with complex medical needs experienced significant, unaddressed weight loss due to inadequate monitoring, lack of updated care plan interventions, and insufficient interdisciplinary communication. Both residents reported dissatisfaction with their diets and did not receive appropriate dietary modifications or supplements in a timely manner, despite clear evidence of nutritional decline.
A resident with a PICC line had a soiled dressing that was not changed according to physician orders and facility policy, despite visible signs of soiling and documentation discrepancies. The DON confirmed the dressing was not changed as required, and the facility's infection prevention policy was not followed.
The facility did not consistently post the Daily Nursing Staffing form as required, with outdated information displayed at the entrance and no posting on the 2nd floor. Staff interviews confirmed the form was not updated daily and was only posted at the front, and there was no facility policy addressing this requirement.
A medication error rate of 6.67% was identified when an LPN administered medications to a resident after updating orders for a probiotic and stool softener, but before the new orders were scheduled to begin. The LPN did not follow facility policy to confirm the timing of medication orders on the MAR prior to administration, resulting in two errors during thirty observed opportunities.
A resident with a history of stroke, dementia, and dysphagia, who required staff assistance and supervision during meals, was left unsupervised with a meal tray and consumed food without help. Staff failed to check the care plan or provide the necessary support, and the resident received an incorrect food item. The resident was later found unresponsive, required emergency interventions, and died after being transported to the hospital. The deficiency was due to staff not following the care plan and not ensuring proper supervision and dietary management.
A resident with dementia, dysphagia, and a history of stroke, who required staff assistance and supervision during meals, was left unsupervised with a meal tray. Staff failed to follow the care plan and did not check the resident's needs before providing the meal. The resident was later found unresponsive after eating alone, required emergency interventions, and subsequently died. The deficiency was due to staff not implementing required care plan interventions for safe feeding.
A resident with dementia, dysphagia, and a history of stroke was left unsupervised and without assistance during a meal, despite care plan and speech therapy recommendations requiring staff support. The resident consumed her meal alone, was later found unresponsive, and emergency interventions were initiated for suspected choking. Documentation and interviews confirmed that staff did not follow the care plan or provide the necessary supervision, leading to the resident's death.
Failure to Coordinate and Reschedule ENT Appointment for Resident with Vertigo
Penalty
Summary
The deficiency involves the facility’s failure to coordinate and follow through with an outside Ear, Nose and Throat (ENT) medical appointment for one resident. On 04/08/2026, the resident was observed in bed in a nightgown and reported having vertigo and being scheduled to see an ENT specialist. He stated that on the day transportation arrived for the appointment, he was not ready because no one at the facility had informed him of the appointment, and that this occurred about a month prior. He further stated the facility told him the appointment would be rescheduled, but it never occurred. Record review showed the resident was originally admitted on 10/10/2023 and readmitted on 02/26/2026 with diagnoses including Type 2 DM with diabetic neuropathy, heart failure (unspecified), and CKD stage 3A. An order summary dated 04/08/2026 showed an ENT appointment scheduled for 02/11/2026 at 11:00. In an interview, an RN confirmed the resident had an ENT appointment on 02/11/2026 for vertigo that had to be rescheduled and stated that Medical Records staff are responsible for scheduling appointments, but she did not know if the appointment was ever rescheduled. The CNA/Medical Records staff member reported that the NP had informed her that the resident wanted to see the ENT, but she was not made aware that the appointment needed to be rescheduled after it was missed. She stated that on a Monday shortly before the survey, the NP asked if she had rescheduled the ENT appointment, and she told the NP she would get to it but did not reschedule it because she did not have time. The DON stated his expectation that appointments should be followed up on timely. The facility’s Transportation Services policy, dated 02/2025, states that the facility will arrange transportation services as needed to ensure each resident receives a complete continuum of service consistent with the plan of care and outlines procedures for notifying the Medical Records designee and rescheduling appointments when necessary, which were not followed in this case.
Insufficient Kitchen Staffing and Inappropriate Use of CNAs
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service on four out of eight days reviewed. Observations and punch detail reports showed that on multiple occasions, only one cook and one dietary aide were present for meal shifts, and certified nursing assistants (CNAs) were pulled from their regular assignments to assist in the kitchen. Staff interviews confirmed that it was common for the kitchen to be understaffed, resulting in delays in meal service, use of disposable serving ware due to lack of dishwashing support, and CNAs being reassigned without coverage for their original duties. The interim Food Services Manager was unsure about the adequacy of kitchen staffing, and the Staffing Coordinator acknowledged that CNAs had to fill in for kitchen staff, though she claimed it was not frequent. Further interviews revealed that when CNAs were moved to the kitchen, their floor assignments were not always covered, leading to missed resident care tasks such as showers. The Nursing Home Administrator stated that the Dietary Manager was responsible for kitchen staffing and that CNAs were not given additional training when assisting in the kitchen, as their duties were limited to tray service. Facility policy required ongoing monitoring and evaluation of staffing adequacy, but the documented practices and staff statements indicated that these procedures were not consistently followed, resulting in insufficient kitchen staffing and disruption of both dietary and resident care services.
Widespread Food Storage, Sanitation, and Hand Hygiene Failures in Dietary Services
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen and nourishment rooms regarding food storage, labeling, sanitation, and staff hygiene practices. Numerous food items in the walk-in refrigerator, freezer, and dry storage were found to be undated, unlabeled, and in some cases, visibly spoiled or contaminated with bio growth. Open containers of milk, fruit bowls, and various other food items lacked proper labeling and dating, while some produce and meats were observed with mold or other signs of spoilage. Additionally, food items were not always stored in accordance with professional standards, with raw meats improperly stored and prepared foods left uncovered or inadequately covered. Staff were repeatedly observed failing to follow proper hand hygiene and glove use protocols. Several dietary staff members were seen moving between tasks such as plating food, handling dirty dishes, and performing temperature checks without washing hands or changing gloves as required. Staff were also observed scratching their heads, picking items up from the floor, and then resuming food preparation duties without performing hand hygiene. These lapses occurred despite facility policies mandating hand washing before and after glove use, between tasks, and after contact with unsanitary surfaces. Sanitation and cleaning logs were incomplete or missing, with dishwashing and refrigeration temperature logs showing multiple unrecorded dates. The kitchen environment was found to be unsanitary, with dirty pots and pans left in sinks, food particles and bio growth present in various areas, and evidence of insect activity near dishwashing equipment. The facility's own policies require daily, weekly, and monthly cleaning schedules, as well as proper documentation of cleaning and temperature checks, but these were not consistently followed or documented. Staff interviews confirmed a lack of adherence to established procedures for food storage, labeling, and sanitation.
Facility Assessment Lacks Emergency and Staffing Details
Penalty
Summary
The facility failed to update its facility-wide assessment to include necessary components such as emergency plans, staff competencies required for caring for residents with varying acuity levels, and specific staffing needs for each shift. Review of the existing facility assessment revealed it lacked sections addressing these critical areas. During interviews, the Staffing Coordinator indicated she was unaware of the facility assessment and based daily staffing solely on the current census, without reference to a comprehensive assessment. The Nursing Home Administrator reported updating the assessment upon arrival to the facility, focusing on a general overview of the building, residents, services, and employee information, but did not include the required details regarding emergency preparedness, staff competencies, or shift-specific staffing needs. No policy related to the facility assessment was provided.
Infection Control Lapses in Meal Service, Laundry, and Sharps Management
Penalty
Summary
Surveyors observed multiple failures in the facility's infection prevention and control program. Meal carts on two separate floors were left open and unattended, exposing unused food trays in foam containers to the environment. Staff were seen delivering meal trays to residents without offering hand hygiene prior to meals in one hallway and two dining rooms. Additionally, eating utensils were left open to the environment and unattended while staff passed meal trays. The facility's hand hygiene policy did not address providing residents with hand hygiene before meals. In the laundry room, several infection control lapses were noted. A personal cell phone was found on the table used for folding linens, and the wall air conditioning unit and a floor fan, both in use, were covered in dust. One dryer was not working and was being used to store clean clothes, while the vents under other dryers contained lint. The area around the washers was dirty, with water stains, a soiled blanket on the floor, and uncleanable porous foam tubes with crusty substances on one washer. Staff interviews confirmed that some of these issues had been ongoing and that cleaning practices were not consistently effective. A resident receiving dialysis was observed with a red-stained towel under the left upper arm, reportedly from a bleeding dialysis site, and had long, dirty fingernails. The resident stated that staff did not offer hand hygiene before meals. Additionally, a sharps container attached to a treatment cart was found to be overfilled, with syringes sticking out above the fill line, contrary to the container's labeling. These findings were supported by photographic evidence and were not in accordance with the facility's infection prevention and control policy.
Failure to Implement and Monitor Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement and monitor its antibiotic stewardship protocol as required. Record reviews and interviews revealed that antibiotic use monitoring was not completed for four consecutive months. Specifically, the Antibiotic Stewardship Book lacked surveillance documentation for August, and the forms for May, June, and July were incomplete and missing required information. The infection mapping for these months was also absent. The DON, who serves as the Infection Preventionist, was unable to locate necessary forms and had not provided education to nurses on how to properly complete the surveillance forms. Additionally, she acknowledged that she had not educated staff on infection control practices. The facility's policy requires comprehensive documentation for antibiotic prescriptions, including dose, route, duration, start and end dates, planned days of therapy, and indication. Audits of antibiotic prescriptions and monitoring of community-acquired infection prevalence data are also mandated, with findings to be presented at monthly Quality Assurance meetings. However, the DON could not provide evidence of such discussions or documentation for several months, nor could she locate point prevalence rates for the same period. The DON stated that she does not allow prophylactic antibiotic orders by physicians, but the lack of surveillance and documentation indicates the protocol was not followed as outlined in facility policy.
Failure to Maintain Safe and Homelike Environment Due to Building Disrepair
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment in two of its four wings, specifically 100 East and 200 East. During facility tours, multiple rooms were found with holes in the walls, peeling ceilings, unpainted walls, missing baseboards, and bio growth on window sills. These deficiencies were directly observed on two separate dates, with photographic evidence obtained. The Maintenance Director acknowledged responsibility for building upkeep but admitted that a comprehensive room-to-room review had not been completed. The process for reporting and addressing maintenance issues involved staff entering work orders into an electronic system, which the Maintenance Director then prioritized. However, only one room with wall damage was listed as open or in progress in the work order documentation, despite the multiple deficiencies observed. During interviews, the Maintenance Director was unable to provide explanations for the unresolved issues in several rooms and stated there was no current resolution for fixing certain problems, such as ceiling damage or relocating residents from affected areas. Review of the facility's policies and the Maintenance Director's job description confirmed the expectation for maintaining the building in good repair and ensuring a safe environment for residents. Despite these requirements, the observed conditions indicated a failure to uphold these standards in the affected wings.
Failure to Provide Scheduled Resident Activities
Penalty
Summary
The facility failed to provide scheduled activities for residents on three out of four days observed. Observations on multiple occasions throughout the days revealed that no activities were conducted as listed on the activity calendar, including events such as Pokeno, Blackjack, Church, Room Visits, Movement and Music, Sing a Long, Bingo, and Movie Monday. The activity calendar indicated that these activities were planned, but they did not occur as scheduled. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) confirmed that the absence of the Activity Director, who had been out since the previous Friday, and the subsequent call-out of the assigned replacement, resulted in no one being available to conduct activities. The NHA acknowledged that there should have been coverage for activities when the Activity Director was unavailable. Review of the facility's policy indicated that activities should be provided at a frequency to meet the individual needs of residents, including their medical, emotional, spiritual, therapeutic, and recreational needs.
Failure to Offer and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were consistently offered and administered the Influenza and Pneumococcal vaccines as required. Record reviews for four out of five sampled residents revealed that several were not offered the Influenza vaccine, and for those who were, there was no documentation indicating receipt of the vaccine. Similarly, some residents were not offered the Pneumococcal vaccine, and for others, there was no documentation of administration despite being offered. The facility's policy requires annual offering and documentation of these vaccines, including obtaining consent and physician orders, but these steps were not consistently followed. During an interview, the DON, who also serves as the Infection Preventionist, stated she had not checked residents' immunization status and was waiting on a new code from Florida Shots. She also acknowledged that she had not provided education to residents regarding the vaccines, although the facility policy requires staff to complete a form when education is provided. The lack of adherence to policy and incomplete documentation contributed to the deficiency in ensuring residents were properly offered and administered the required vaccinations.
Failure to Offer and Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to ensure that residents were properly offered and documented for the COVID-19 vaccine, as evidenced by record reviews and interviews. Specifically, three out of five sampled residents were not managed according to facility policy: one resident was not offered the COVID-19 vaccine at all, while two others were offered the vaccine but had no documentation indicating whether they received it. The facility's policy requires that all residents be offered the COVID-19 vaccine and any eligible boosters, with proper documentation of administration, consent, or declination in the medical record. During an interview, the DON, who also serves as the Infection Preventionist, stated she had not checked any residents' immunization status and was waiting on a new code from Florida Shots. She also acknowledged that she had not provided education to any residents regarding the COVID-19 vaccine, despite the existence of a form for documenting such education. The facility's policy outlines specific procedures for offering, obtaining consent, and documenting immunizations, which were not followed in these cases.
Failure to Follow Grievance Process for Laundry-Related Complaints
Penalty
Summary
The facility failed to follow its grievance process for a resident who reported multiple issues with missing and damaged clothing, as well as concerns about laundry practices. The resident, who had diagnoses including type 2 diabetes and chronic kidney disease, reported missing three pairs of cargo pants and damage to other clothing items after laundering. Despite the resident filing grievances and being told the items would be replaced, the facility did not provide evidence that the items were replaced or that the grievances were resolved. Documentation in the grievance log and reports was incomplete, with missing resolution dates and lack of confirmation that the issues were addressed. The Nursing Home Administrator was unable to specify what actions had been taken regarding the grievances and acknowledged that grievances were marked as completed without the required follow-up or proof of resolution. Additionally, during a resident council meeting, multiple residents expressed concerns about the facility's slow response to grievances, particularly regarding laundry issues. Residents reported missing and damaged clothing and a lack of communication about the outcomes of their grievances. The facility's grievance policy requires prompt efforts to resolve concerns and documentation of resident satisfaction upon completion, but these procedures were not followed as evidenced by incomplete records and unresolved issues.
Deficient PASRR Screening and Documentation for Mental Illness and Intellectual Disability
Penalty
Summary
The facility failed to complete a required Level II Pre-admission Screening and Resident Review (PASRR) for one resident and did not ensure the accuracy of a Level I PASRR for another. One resident was admitted with diagnoses including unspecified bipolar disorder, insomnia, and depression, and their PASRR indicated diagnoses of bipolar disorder, depressive disorder, and PTSD. Despite these diagnoses and the resident exhibiting symptoms of depression following the loss of a spouse, the PASRR did not identify any disorder resulting in functional limitations or issues with interpersonal functioning, and it was determined that a Level II PASRR was not required. The resident's care plan, however, included trauma-informed care for PTSD and the use of psychotropic medications for bipolar disorder and insomnia. The Director of Clinical Reimbursement confirmed that a Level II PASRR should have been completed for residents with such diagnoses who remain in the facility for more than 30 days. For another resident, the facility did not update the Level I PASRR to reflect new diagnoses of anxiety and insomnia that were added after the initial admission. The PASRR only listed depressive disorder, omitting the later diagnoses. The Director of Clinical Reimbursement stated that updating PASRRs is typically the responsibility of Social Services, but there was uncertainty about the regular review process for PASRRs and whether all relevant diagnoses were being consistently documented. The facility's policy requires preadmission screening and review of PASRRs for suspicion of serious mental illness or intellectual disability, but these procedures were not followed as required in these cases.
Failure to Provide Adequate Nail Care for Two Residents
Penalty
Summary
Surveyors identified that the facility failed to provide adequate nail care for two residents who were sampled for activities of daily living (ADLs). One resident was observed multiple times with fingernails extending 1/3 to 1/2 inch past the fingertips, discolored, and with a dark substance present. The resident reported not wanting long fingernails and stated that staff had not offered to cut them, with documentation showing nail care was only provided eight out of twenty-seven days. The resident's care plan indicated a self-care performance deficit related to weakness and activity intolerance, as well as impaired cognitive function due to dementia, but did not address any behaviors related to refusing care. Staff interviews confirmed that nail care should be provided by CNAs or nurses, with special consideration for diabetic residents. Another resident was observed with long fingernails and a dark brown substance caked underneath. This resident expressed a preference for regular nail care and reported that staff did not mention or offer to cut fingernails, and that toenail care was only provided once every two months. The resident indicated willingness to perform self-care if supplies were available. Documentation revealed several days where nail care was not provided, and shower logs were incomplete for the requested period. Staff interviews indicated that refusals for ADL care were not consistently documented with reasons, and that ADL care may not be provided when CNAs are assigned to other duties. The facility's care plan for one resident instructed staff to check and trim nails on bath days and as necessary, but records showed this was not consistently done. The facility lacked a specific ADL policy, and the process for documenting refusals was not always followed according to the facility's own declination form. Photographic evidence was obtained to support the findings.
Failure to Assist Dependent Resident with Transfers and Activities of Daily Living
Penalty
Summary
A deficiency occurred when a dependent resident was not provided assistance to get out of bed, despite being unable to perform this activity independently. Observations on multiple occasions showed the resident lying in bed with her call light within reach, reporting that staff would not assist her to the toilet or help her attend activities. The resident, who had diagnoses including muscle wasting, atrophy, a femur fracture, and diabetes, was cognitively intact according to her BIMS score. Her care plan specified that she required assistance from one staff member for transfers, with the goal of preventing decline in her ability to perform activities of daily living (ADLs). Interviews revealed that a CNA assigned to the resident had not assisted her out of bed and only did so when residents specifically requested it. The DON confirmed that all residents should be offered the opportunity to get out of bed, regardless of whether they ask. The CNA job description also outlined responsibilities for assisting residents with transfers and mobility. The failure to provide necessary assistance resulted in the resident remaining in bed and missing activities, contrary to her care plan and facility policy.
Failure to Provide Timely Podiatry Services for Resident with Foot Care Needs
Penalty
Summary
The facility failed to assess and obtain podiatry services for a resident with significant foot care needs. Observations revealed that the resident's toenails were malformed, thickened, discolored, and extended past the tips of the toes. The resident expressed a need for a podiatrist to cut their toenails. Staff interviews indicated that the resident's name was placed in a folder for the Social Worker to add to the podiatry list, but the issue had not been previously brought to the attention of nursing staff by aides. Documentation showed that nail care was provided as needed, but did not specify whether this included toenails, and there was no evidence that the resident had refused podiatry or nail care services. The resident had multiple medical diagnoses, including chronic respiratory failure, end stage renal disease, and dependence on dialysis, and was cognitively intact. Physician orders allowed for podiatry services as needed, and the care plan required assistance with personal hygiene. Interviews with facility leadership revealed uncertainty about the frequency of podiatry visits and a lack of clarity regarding the process for referring residents to podiatry services. The deficiency was identified through observations, record reviews, and staff interviews, which demonstrated a breakdown in communication and follow-through regarding the resident's foot care needs.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient monitoring or supervision in the affected area. No additional details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Nutritional Status and Address Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status, specifically body weight, for two residents who experienced significant weight loss. One resident, with multiple diagnoses including muscle wasting, anemia, dysphagia, diabetes, and depression, lost 15.15% of body weight since admission. Despite triggering for significant weight loss, the care plan and interventions were not updated after the loss was identified. The resident reported not eating the provided food due to dislike and not being offered alternatives or snacks, and staff interviews confirmed a lack of new dietary interventions following the weight loss. Another resident, also with complex medical conditions such as muscle wasting, dysphagia, and GERD, lost 8.31% of body weight in just over a month. The resident was on a pureed diet and reported not liking the food, having difficulty eating due to dental issues, and not receiving adequate dietary variety. The nutrition evaluation noted the resident was not meeting estimated nutritional needs, and although a supplement was recommended, the care plan did not reflect updated interventions after the significant weight loss was discovered. The order for weekly weights, as recommended by the dietitian, was not present in the physician orders. Interviews with staff, including the DON and SLP, revealed a lack of awareness and communication regarding the residents' weight loss. The SLP was not informed of the weight loss, and the DON was unaware of the extent of the issue or the absence of weekly weight orders. The facility's policy required more frequent monitoring and interdisciplinary communication for significant weight loss, but these steps were not documented or implemented for the affected residents.
Failure to Change Soiled PICC Line Dressing per Policy
Penalty
Summary
The facility failed to ensure the intravenous catheter dressing for a resident with a peripherally inserted central catheter (PICC) was changed according to professional standards and facility policy. Observations revealed that the resident's PICC line dressing was soiled, with a dark dry-looking substance and a red wet-looking substance visible under the clear dressing. The dressing was dated several days prior and had not been changed as required. Review of the resident's physician orders indicated that the IV dressing was to be changed every 7 days and as needed (PRN) for soiling or dislodgement. However, the Medication Administration Record (MAR) showed that while the dressing was documented as changed on certain dates, it was not actually changed when soiled, as required by the orders. Interviews with the Director of Nursing (DON) confirmed that the dressing had not been changed as documented and that the dressing should have been changed when soiled. The facility's infection prevention policy required transparent, semi-permeable membrane dressings to be changed at least every 7 days and PRN if the dressing became wet, loose, soiled, or if skin integrity was compromised. The failure to change the dressing as needed for soiling was confirmed through observation, record review, and staff interviews.
Failure to Appropriately Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to appropriately post the Daily Nursing Staffing form as required. Observations revealed that the posted form near the reception area was outdated, displaying a date from three days prior. Additionally, the Daily Nursing Staffing form was not posted on the 2nd floor during multiple observations over several days. Interviews with the Staffing Coordinator and the Nursing Home Administrator confirmed that the form was only posted at the entrance and not updated daily as required. It was also noted that the facility did not have a policy related to the posting of the nursing staffing form.
Medication Error Rate Exceeds 5% Due to Improper Timing of Order Changes
Penalty
Summary
The facility failed to maintain a medication error rate below 5.00%, as evidenced by two medication errors identified during the observation of thirty medication administration opportunities. Specifically, an LPN administered nine medications to a resident, including changes to the resident's probiotic and stool softener, after receiving new orders from the provider. The LPN updated the electronic medication profile and administered the medications, but the new orders for docusate (from capsule to tablet) and for the probiotic (from lactobacillus to saccharomyces) were scheduled to begin at later times, not at the time of administration. The LPN documented the administration in the electronic record, but the timing did not align with the scheduled start of the new orders. Review of the resident's Medication Administration Record (MAR) confirmed that the previous orders for docusate and lactobacillus were discontinued just prior to the administration, and the new orders were set to begin later in the day. The DON confirmed that both medications should have been administered after the new orders became active. Facility policy requires staff to review and confirm medication orders on the MAR prior to administration, but this procedure was not followed, resulting in a medication error rate of 6.67%.
Failure to Provide Required Supervision and Assistance During Meals Resulting in Resident Death
Penalty
Summary
A deficiency occurred when facility staff failed to protect a resident from neglect by not ensuring supervision and assistance during mealtimes, despite the resident's documented need for such support due to a history of cerebral infarction, dementia, and dysphagia. The resident was dependent on staff for feeding, as indicated in her care plan and medical records, which specified a mechanically altered diet and substantial/maximal assistance with eating. On the day of the incident, staff provided the resident with a covered food tray in her room and left her unsupervised, allowing her to consume her meal without the required assistance or monitoring. The resident was later found unresponsive by her roommate, who alerted a nurse. Facility staff initiated emergency interventions, including the Heimlich maneuver and CPR, and Emergency Medical Services were called. The resident was transported to the hospital, where she expired. Interviews and documentation revealed that staff did not check the resident's care plan prior to providing the meal, and there was a lack of communication and understanding among staff regarding the resident's need for supervision and assistance during meals. Additionally, the resident received the wrong food item on her tray, which was not consistent with her prescribed diet. Further investigation showed that the resident's family and speech language pathologist had previously communicated the need for supervision during meals due to the resident's tendency to eat too quickly and her inability to sense food on one side of her mouth. Despite these recommendations, staff routinely left the resident to feed herself and did not provide the necessary supervision or assistance. The facility's failure to follow the care plan and ensure proper supervision and dietary management directly contributed to the resident's choking incident and subsequent death.
Removal Plan
- Resident #2 discharged to the hospital and has not returned to the facility.
- The facility incorporated an additional notification on resident meal tickets through the meal tracker system to ensure facility staff are aware of the care and services needed by residents to include supervision and/or assistance during mealtimes in order to prevent further instances of neglect. The addition of this tray ticket notification indicator was complete.
- The DON and NHA received directed education by the Regional Nurse Consultant regarding abuse, neglect, and misappropriation as they relate to ensuring proper resident supervision and/or assistance during meals.
- Facility staff were provided education by the DON or designee regarding abuse, neglect, and misappropriation as they relate to ensuring proper resident supervision and/or assistance during meals. Contracted staff members were provided education regarding abuse, neglect, and misappropriation. Nursing and therapy staff were provided education by the DON or designee on ensuring proper resident supervision and/or assistance during meals. Education regarding the added notification on resident meal tickets was provided including the meaning of the indicator and what to do when they see it. This education was completed.
- An ad hoc Quality Assurance Meeting was held with the MD regarding removal plan activities. This meeting was held.
Failure to Implement Care Plan Interventions for Assisted Dining
Penalty
Summary
A deficiency occurred when facility staff failed to implement care plan interventions for a resident with a history of cerebral infarction, dementia, and dysphagia, who was dependent on staff for feeding and required supervision during meals. Despite clear documentation in the care plan and recommendations from the speech language pathologist for close supervision and assistance with eating, the resident was left unsupervised with a meal tray in her room. Staff did not check the care plan prior to providing the meal, and the resident consumed food without the required assistance or supervision. The resident, who had moderate cognitive impairment and was on a mechanically altered diet, was found unresponsive after eating unsupervised. Interviews and medical record reviews confirmed that the resident had a history of difficulty swallowing, required a mechanically soft diet, and was dependent on staff for eating. The care plan specifically indicated the need for one staff member to assist with eating and for supervision due to the resident's cognitive deficits and swallowing risks. However, staff members, including CNAs and LPNs, did not follow these interventions, and some were unaware of the resident's needs, relying instead on verbal shift reports or assumptions about the resident's abilities. As a result of these failures, the resident was discovered unresponsive with food present, required emergency interventions including the Heimlich maneuver and CPR, and was subsequently transported to the hospital, where she expired. The investigation revealed that staff did not consistently review or implement care plan interventions, and the resident was not provided the necessary supervision and assistance during meals as required by her care plan and physician orders.
Removal Plan
- Resident #2 discharged to the hospital and has not returned to the facility.
- An audit was completed of care plans for current residents related to necessary dietary interventions to ensure that residents requiring assistance receive appropriate care during mealtimes as per the resident care plan and CNA documentation system. The audits for meal tray accuracy and appropriate level of assistance were initiated and is currently ongoing. There are currently 50 audits at this time. The tray line audit reviewing adequate consistency and items matching meal tickets was initiated and is ongoing, there are currently 118 audits at this time.
- The DON and NHA received directed education by the Regional Nurse Consultant on ensuring that resident care plans are implemented during meal times and ensuring that staff have knowledge of the resident care plan/CNA documentation system interventions.
- A total of 90 out of 90 Licensed nursing staff and Certified Nursing Assistants were provided education by the DON or designee on ensuring that resident care plans are implemented during meal times and ensuring that staff have knowledge of the resident care plan/CNA documentation system interventions. This education was 100% completed.
- An ad hoc Quality Assurance Meeting was held with the MD regarding removal plan activities.
Failure to Provide Required Supervision and Assistance During Meals Resulting in Resident Death
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, dementia, and dysphagia was not provided the required supervision and assistance during mealtime, as outlined in her care plan and supported by speech therapy recommendations. The resident was dependent on staff for feeding and required a mechanically altered diet, yet staff failed to check her care plan before delivering her meal tray and left her unsupervised in her room. The resident consumed her meal without assistance, despite documented needs for close supervision due to her cognitive impairment and swallowing difficulties. On the day of the incident, the resident was found unresponsive by a nurse after her roommate alerted staff. The nurse and other staff initiated emergency procedures, including CPR and the Heimlich maneuver, due to suspected choking. EMS arrived and continued resuscitation efforts, noting the presence of emesis and food in the resident's airway. The resident was transported to the hospital, where she later expired. Documentation and interviews confirmed that the resident had not been consistently assisted or supervised during meals, and her care plan interventions were not followed by the staff responsible for her care. Interviews with facility staff, the resident's family, and the speech language pathologist revealed that the resident's need for supervision and assistance during meals was known but not consistently communicated or implemented. Staff members involved in meal delivery and care did not review the care plan or receive adequate handoff information regarding the resident's needs. The failure to provide supervision and assistance during meals, as required by the resident's care plan and clinical recommendations, directly led to the resident's choking incident and subsequent death.
Removal Plan
- Resident #2 discharged to the hospital and has not returned to the facility.
- The facility incorporated an additional notification on resident meal tickets through the meal tracker system to ensure facility staff are aware of the care and services needed by residents to include supervision and/or assistance during mealtimes in order to prevent further instances of neglect. The addition of this tray ticket notification indicator was complete.
- The DON and NHA received directed education by the Regional Nurse Consultant regarding ensuring proper resident supervision and/or assistance during meals is occurring.
- A total of 104 out of 104 nursing and therapy staff were provided education by the DON or designee on ensuring proper resident supervision and/or assistance during meals. Education regarding the added notification on resident meal tickets was provided including the meaning of the indicator and what to do when they see it. This education was 100% completed.
- An ad hoc Quality Assurance Meeting was held with the MD regarding removal plan activities.
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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