Douglas Jacobson State Veterans Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Port Charlotte, Florida.
- Location
- 21281 Grayton Terrace, Port Charlotte, Florida 33954
- CMS Provider Number
- 106059
- Inspections on file
- 21
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Douglas Jacobson State Veterans Nursing Home during CMS and state inspections, most recent first.
A resident with Parkinson's and Alzheimer's, who was alert and oriented, was denied access and assistance to a bathroom in the therapy department, resulting in an incontinence episode and a missed medical appointment. Therapy staff did not provide direct toileting assistance or seek help from nursing, instead blocking the bathroom door and insisting the resident return to his unit. The resident reported feeling angry and embarrassed by the incident.
Two residents received controlled substances with documentation showing more doses administered than prescribed, and medication logs were found to be illegible and inconsistent. An LPN was associated with multiple discrepancies, including altered dates and unclear signatures, leading to inaccurate records of medication administration.
A resident with intact cognition and overactive bladder reported that call lights were ignored and care was not provided during the night shift, resulting in the resident being found in the morning with a full urinal, wet bed, and soiled brief. Staff interviews revealed inconsistent accounts of care, and documentation was lacking to confirm that care was provided or refused. The facility's investigation verified the neglect allegation due to insufficient evidence to disprove the resident's claim.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident did not receive timely toileting assistance during the night shift, resulting in being found wet and soiled in the morning, with no documentation of care or refusals. Additionally, two residents experienced discrepancies in the administration and documentation of controlled substances, with records showing more doses given than prescribed and illegible, altered logs. Staff interviews confirmed these failures, and one LPN was linked to multiple documentation issues.
Two residents receiving scheduled Oxycodone-based pain medications experienced discrepancies in the administration and documentation of their controlled substances. The medication logs showed more doses signed out than prescribed, with illegible and altered entries, and dates out of order. An LPN was associated with these documentation errors, admitting to changing dates and being unable to account for multiple signatures, resulting in a failure to protect residents from misappropriation of their property.
A resident with dementia, Parkinson's disease, and overactive bladder was found with a full urinal and wet bedding after reporting that call lights were not answered during the night. Staff interviews provided conflicting accounts, and there was no documentation of incontinence care or refusals for the shift in question or for several other days. The lack of records prevented verification that care was provided, leading to a substantiated finding of neglect.
A resident with Parkinson's and dementia was reportedly bruised during an incident where staff attempted to clean him after he smeared feces on his bed. The resident became combative, and staff held his hands and wrists to prevent him from falling and to protect themselves. The resident's family reported concerns about bruising, and the resident confirmed staff had grabbed him, although he did not feel it was intentional harm. The facility's investigation did not verify abuse, but the Risk Manager noted staff should not have forcibly removed the resident from the bed.
A facility failed to protect residents from neglect by not following hot liquid safety procedures, leading to burns for two residents. One resident spilled hot coffee, causing redness, while another with severe cognitive impairment suffered a second-degree burn from hot chocolate. An LPN reheated the drink without checking its temperature, violating policy. No audits ensured staff compliance, resulting in injuries.
A resident with cognitive impairments suffered a second-degree burn after a staff member reheated hot chocolate without checking the temperature, contrary to facility policy. The resident accidentally spilled the hot beverage, resulting in an avoidable injury. The staff member had been trained on safe serving practices but failed to adhere to them.
A resident with a complex medical history fell and sustained a head injury, leading to a significant drop in blood pressure. The LPN failed to notify the physician of the change in condition or perform a complete neurological assessment, resulting in the resident being found with no vital signs. The medical director stated that he would have sent the resident to the ER if informed of the mental status change.
A resident with Parkinson's disease and dementia, identified as high risk for falls, experienced multiple falls due to inadequate supervision in an LTC facility. Despite a care plan requiring assistance, the resident was often left unsupervised, leading to injuries. The facility failed to update the care plan with new interventions after each fall, as acknowledged by the DON.
A resident with Parkinson's disease and dementia, identified as a high fall risk, experienced 18 falls without adequate updates to their care plan. Despite multiple falls, the facility only added new interventions twice. The DON noted the resident's cognitive limitations and the challenge of implementing effective interventions without compromising independence.
The facility failed to provide an ongoing activity program to meet the interests and support the well-being of its residents. A resident with dementia and Parkinson's was observed restless and disengaged from activities. Another resident with Alzheimer's was found sleeping or passively sitting without structured activities. A third resident with severe cognitive and sensory impairments was not engaged in meaningful activities. Staff shortages and lack of qualified personnel contributed to the deficiency.
The facility failed to have a qualified Activity Director, impacting the activities program. Staff lacked necessary credentials, and the absence of a qualified director since early August led to limited activities, especially for residents in secured units. An interim director was present for a week, but the deficiency affected all residents' well-being.
A resident with multiple medical conditions experienced a fall with a head injury. The LPN failed to complete necessary neuro checks, noting the resident was asleep and did not want to wake him, despite a significant drop in blood pressure. The facility lacked a policy for neuro checks, and the resident was later found with no vital signs.
The facility failed to provide two residents with the required Skilled Nursing Advanced Beneficiary of Non-Coverage form (CMS-10123) in a timely manner, as per policy. The notice, which should be given at least two days before the end of a Medicare-covered Part A stay, was not documented as provided within the required timeframe. Staff K, the social worker program manager, admitted to sending notices via regular mail without documentation of the timing, leading to the deficiency.
Resident Denied Restroom Access and Assistance in Therapy Department
Penalty
Summary
A deficiency occurred when a resident was denied access and assistance to a bathroom in the therapy department, resulting in an incontinence episode. The incident took place when the resident, who was on his way to a doctor's appointment, urgently needed to use the restroom and attempted to use the therapy department bathroom. Staff in the therapy department informed the resident that he could not use the restroom without assistance and that he was not permitted to use the therapy bathroom unless he was in treatment. The staff offered to take the resident back to his unit to use the bathroom, but did not offer direct assistance with toileting in the therapy department. Additionally, a wheelchair was placed in front of the bathroom door to block access, and no staff contacted the nursing department for assistance. The resident, who had diagnoses of Parkinson's disease and Alzheimer's disease, was alert and oriented with intact cognition, as indicated by a recent assessment. He required assistance for transfers (stand and pivot) and sometimes used a sit-to-stand lift, but therapy notes indicated he was able to use the restroom with minimal to no assistance. Despite his ability to communicate his needs and his history of being able to toilet himself, the staff did not provide the necessary support or allow him to use the available restroom, leading to the resident soiling himself and missing his scheduled appointment. Staff statements confirmed that the resident expressed urgency and distress, and that the therapy staff did not personally assist him to the restroom nor did they seek help from nursing staff. The Director of Rehab later stated that the facility's verbal policy is to accommodate all residents' restroom needs and that there was no excuse for denying access. The resident reported feeling angry and embarrassed by the incident, which he described as inconsistent with his prior experiences at the facility.
Failure to Prevent Misappropriation and Inaccurate Documentation of Controlled Substances
Penalty
Summary
The facility failed to protect residents' rights to be free from misappropriation of property by not maintaining effective processes to prevent the misappropriation of controlled substances for two residents. For one resident, a physician's order specified a controlled substance to be administered four times daily, but pharmacy records and controlled substance logs revealed that the medication was being signed out and documented as administered more frequently than prescribed, with some days showing up to 11 doses. The controlled substance logs were found to have multiple dates scribbled over or written illegibly, making it difficult to determine the actual administration times and dates. Despite the discrepancies, the physical count of medication matched the expected amount, but the documentation did not align with the prescribed administration schedule. A similar issue was identified for another resident, where the controlled substance record of use also showed illegible and out-of-order dates, and the number of tablets signed out did not match the administration history. The logs indicated that more tablets were being signed out than were actually administered according to the administration history, and the documentation was inconsistent and unclear. The facility's investigation found that these discrepancies were associated with a specific LPN, who admitted to changing dates on medication documents and could not account for multiple signatures or events on the medication cart. The LPN denied taking any pills or overmedicating residents but acknowledged making documentation errors. The deficiencies were discovered when the pharmacy consultant identified that a refill request for a controlled substance was made earlier than expected, prompting an audit of the controlled substance records. The audit revealed that the documentation did not accurately reflect the administration of medication as ordered by the physician, and the logs were not maintained in a legible or orderly manner. The facility's own investigation confirmed the documentation issues and linked them to the actions of the LPN involved.
Failure to Prevent Resident Neglect Due to Lack of Night Shift Care and Documentation
Penalty
Summary
A deficiency occurred when a resident's right to be free from neglect was not upheld, as the facility failed to ensure the resident received necessary care during the night shift. The resident, who had diagnoses including overactive bladder and required partial assistance for mobility and toileting, reported that he called for help throughout the night but did not receive assistance. Upon morning shift change, staff found the resident with a full urinal, wet bed, and soiled brief, confirming that his care needs had not been met during the previous shift. Interviews with staff revealed inconsistencies in the accounts of care provided. Some CNAs and nurses stated that the resident was checked and attended to multiple times during the night, while others acknowledged that it was not uncommon to find residents with overflowing urinals and soaked beds at the start of the morning shift. The resident himself reported frequent issues with the night shift not responding to call lights, and described an incident where a nurse entered his room, turned off the call light, and left without providing care, despite his bed being soaked. A review of the clinical record and facility documentation showed a lack of evidence that care was provided or that the resident refused care during the night in question. The facility's own investigation verified the allegation of neglect, noting that there was insufficient documentation to disprove the resident's claim. The Director of Nursing confirmed the absence of documentation for care provided to the resident on multiple shifts, and staff interviews indicated that there was no clear policy for documenting such care.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent Neglect and Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to protect residents' rights to be free from neglect and misappropriation of property, as evidenced by two main deficiencies. One resident, who was care planned for overactive bladder and required a two-person assist for transfers and toileting, reported that he called for help throughout the night but did not receive assistance. Multiple staff interviews and the facility's own investigation confirmed that the resident was found in the morning with a full urinal, wet bed, and wet brief, and that there was no documentation of care provided or refusals during the night shift. Staff acknowledged that it was not uncommon to find residents wet and call lights on at shift change, and the Director of Nursing confirmed a lack of documentation for care provided on multiple shifts. Additionally, the facility failed to have effective processes in place to prevent the misappropriation of controlled substances for two residents. Pharmacy records and controlled substance logs revealed that one resident received more doses of a controlled medication than prescribed, with documentation showing up to 11 doses in a single day when only four were ordered. The logs were found to be illegible, with dates scribbled over and not in order, and similar discrepancies were found for another resident's controlled medication. The pharmacy consultant and facility staff confirmed that the counts were correct, but the administration records were inaccurate and not properly reconciled. Interviews with staff, including the DON, Risk Manager, and LPNs, revealed that one LPN was associated with multiple documentation discrepancies, including altered dates and signatures she could not recall. The facility's investigation verified these issues, and the LPN denied taking any pills or overmedicating residents. The lack of accurate documentation and oversight led to the inability to ensure that residents received medications as ordered and that their property was safeguarded.
Failure to Prevent Misappropriation and Inaccurate Documentation of Controlled Substances
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property by not maintaining effective processes to prevent the misappropriation of controlled substances. Specifically, for two residents with physician orders for scheduled doses of Oxycodone-based pain medications, discrepancies were found in the administration and documentation of these controlled substances. The controlled substance logs showed that more doses were signed out than prescribed, with some days reflecting up to 11 doses when only 4 were ordered. Additionally, the logs contained multiple instances of dates being scribbled out, written over, or entered out of order, making it difficult or impossible to accurately track medication administration. For one resident, pharmacy records indicated that 120 tablets of Oxycodone-APAP were delivered as a 30-day supply, but the medication was requested for refill eight days early. Upon review, it was found that the administration history did not match the expected dosing schedule, and the controlled substance logs were inconsistent and illegible in places. The count of tablets in the blister packs matched the documented end count, but the daily administration records showed more doses than prescribed, and missed doses were also documented. Similar issues were identified for another resident receiving Oxycodone, with the controlled substance logs again showing illegible entries and dates out of sequence. The facility's investigation revealed that these discrepancies were associated with an LPN, who admitted to changing dates on medication documents and could not account for multiple signatures. The LPN denied taking any pills or overmedicating residents but acknowledged making documentation errors. The facility identified that the issues were not isolated to a single resident but affected multiple residents receiving controlled substances, and the documentation practices failed to ensure accurate and legible records of controlled substance administration.
Failure to Provide and Document Incontinence Care Resulting in Resident Neglect
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's right to be free from neglect by not ensuring that incontinence care was provided according to the resident's needs. The resident, who had diagnoses including dementia, Parkinson's disease, and overactive bladder, was assessed as frequently incontinent and required partial to moderate assistance for toileting and hygiene. Despite being care planned for urinary incontinence and having urinals at the bedside, the resident reported that call lights were used throughout the night without response, resulting in a full urinal and wet bed and clothing in the morning. Multiple staff interviews confirmed that the resident was found in this condition at shift change, and the resident expressed dissatisfaction with the care received during the night shift. The facility's investigation into the incident revealed conflicting staff accounts regarding the care provided during the night in question. While some staff stated that the resident was attended to multiple times, there was no documentation in the clinical record to support that incontinence care was provided or that the resident refused care during the relevant shift. The lack of documentation extended to several other days and shifts, as verified by the Director of Nursing, indicating a broader issue with record-keeping for incontinence care and resident refusals. The facility's policies required identification and intervention in situations where neglect could occur, but the absence of documentation made it impossible to verify that the resident's needs were met. The investigation ultimately verified the allegation of neglect due to the inability to disprove the resident's claim and the lack of evidence showing that appropriate care was provided during the night shift.
Resident's Right to Be Free from Physical Abuse Not Protected
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse. The incident involved a male resident with a history of Parkinson's disease, dementia, bipolar disorder, major depressive disorder, and obsessive-compulsive disorder. On the night of the incident, the resident was reportedly smearing feces on his bed and became combative when staff attempted to clean him. The staff, consisting of an LPN and a CNA, held the resident by his hands and wrists to prevent him from falling out of bed and to protect themselves from being hit by the resident, who was using a reaching tool as a weapon. The resident's family reported concerns about bruising on the resident's hands and wrists, which they believed resulted from staff forcibly removing him from the bed. The resident confirmed to the Risk Manager that staff had grabbed his hands and wrists, causing bruising, although he did not feel the staff intentionally tried to hurt him. The Risk Manager observed the bruising and noted the resident's mental anguish following the incident, indicating psychological support was being provided. The facility's investigation concluded that the allegation of abuse was not verified, citing the resident's combative behavior and the staff's actions to ensure his safety. However, the Risk Manager acknowledged that staff should not have removed the resident from the bed against his will and did not fully document or investigate the family's claim about prying the resident's fingers from the handrail. The report highlights a deficiency in the facility's handling of the situation, particularly in protecting the resident from potential abuse and adequately investigating the incident.
Failure to Adhere to Hot Liquid Safety Procedures Results in Resident Burns
Penalty
Summary
The facility failed to protect residents from neglect by not adhering to its hot liquid safety procedures, resulting in thermal burns to two residents. The facility's policy required that hot beverages be served at a safe temperature to prevent scalding and burns, with temperatures recorded daily. However, an incident occurred where a resident spilled hot coffee on himself, resulting in redness to his abdomen and upper thigh. This incident highlighted the facility's failure to ensure staff followed the hot liquid safety procedures. Another incident involved a resident with Alzheimer's disease and severe cognitive impairment, who sustained a partial thickness thermal burn after hot chocolate spilled onto his lap. The resident's cognitive skills were severely impaired, requiring setup and cleanup assistance at meals. Despite this, the hot chocolate was served at an unsafe temperature, leading to a burn that evolved from a first-degree to a second-degree burn. The resident reported that the hot chocolate was very hot and spilled from the table onto his lap. The facility's investigation revealed that an LPN reheated the hot chocolate without rechecking its temperature, contrary to the facility's policy. The LPN had previously signed an in-service form acknowledging the requirement to check temperatures before serving. The facility confirmed that no audits were conducted to ensure staff compliance with the hot liquid safety procedures, resulting in the resident's injury.
Failure to Ensure Safe Serving of Hot Beverages
Penalty
Summary
The facility failed to ensure the safe serving of hot beverages, resulting in an avoidable thermal burn for a resident. On the specified date, a staff member reheated a cup of hot chocolate for a resident without verifying that the beverage was at a safe temperature. The resident, who had severe cognitive impairments and required assistance during meals, accidentally spilled the hot chocolate on his lap, leading to a second-degree burn on his left anterior thigh. The facility's policy on hot liquid safety was not followed, as the temperature of the beverage was not checked after reheating, and the resident was not adequately supervised. The resident involved was an elderly male with Alzheimer's disease, dementia, and other health conditions, which impaired his cognitive skills and decision-making abilities. The incident occurred when the resident was in his wheelchair, and the hot chocolate was placed on a bedside table. Despite the resident's preference for cooler beverages, the staff member reheated the drink and added ice chips without ensuring the temperature was safe. The resident reported that he did not request the reheating and that the cup tipped over from the table, causing the burn. The facility's incident investigation revealed that the staff member involved had previously received training on serving hot liquids safely, including checking temperatures before serving. However, the staff member did not adhere to these guidelines, as the temperature was not checked after reheating the beverage. The Director of Nursing and the Risk Manager confirmed that the staff member did not follow the facility's policy, leading to the resident's injury.
Failure to Notify Physician of Change in Condition After Resident Fall
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident who experienced a fall resulting in a head injury. The resident, an elderly male with a complex medical history including Type 2 Diabetes, Dementia, and a cardiac pacemaker, fell and sustained a head injury. Following the fall, the resident complained of a headache and was observed with a reddened spot on his head. Despite these signs, the facility did not adequately monitor or document the resident's neurological status, as evidenced by missing documentation of pupil reaction and hand grasp. The resident's blood pressure showed a significant drop from 152/80 to 100/50, which was not recognized as concerning by the LPN on duty. The LPN did not notify the physician of this change, nor did she perform a complete neurological assessment, citing the resident's sleep as a reason. The resident was later found with no vital signs, and the medical director indicated that had he been informed of the change in mental status, he would have recommended sending the resident to the emergency room.
Inadequate Supervision Leads to Multiple Falls for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent avoidable fall-related accidents for a resident identified as being at high risk for falls. The resident, who had a history of falls and a hip fracture, was diagnosed with Parkinson's disease, dementia, and other mobility issues. Despite being assessed as requiring assistance for transfers, ambulation, and toileting, the resident experienced multiple falls, both witnessed and unwitnessed, over several months. Observations revealed that the resident was often left unsupervised, contrary to the care plan interventions, which included keeping personal items and call lights within reach and using anti-roll backs on the wheelchair. The facility's fall risk assessments consistently indicated a high risk for falls, yet the care plan was not updated with new interventions following each fall. The Director of Nursing acknowledged the lack of documentation for new interventions after falls, except for a few instances. The resident sustained injuries, including skin tears and a rib fracture, following falls. Despite the facility's fall program encouraging frequent rounding, the resident was often found alone in various locations without supervision. The DON expressed uncertainty about further interventions, citing the resident's cognitive limitations and the desire to maintain the resident's independence.
Failure to Update Care Plan for High Fall Risk Resident
Penalty
Summary
The facility failed to review and revise the comprehensive person-centered care plan for a resident based on ongoing clinical assessments and identified risks for falls. The resident, who was admitted with diagnoses including Parkinson's disease, dementia, and mobility issues, was identified as a high fall risk. Despite this, the care plan was not updated with new interventions following multiple falls, except on two occasions. The resident experienced 18 falls, both witnessed and unwitnessed, over a period of time, with some resulting in injuries such as skin tears. The Director of Nursing (DON) acknowledged the lack of documentation for new interventions after each fall, except for the addition of nonskid footwear and a protective bumper on specific dates. The DON expressed uncertainty about further interventions due to the resident's cognitive limitations, suggesting that one-on-one supervision might be necessary but was not implemented to maintain the resident's independence. The facility's fall program included purposeful rounding, but it was not sufficient to prevent the resident's repeated falls.
Deficiency in Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing activity program tailored to meet the interests and support the physical, mental, and psychosocial well-being of its residents. This deficiency was observed in three residents who were not engaged in meaningful activities. Resident #109, diagnosed with dementia, Parkinson's disease, and other conditions, was frequently observed sitting in front of a TV without awareness or interest in the program. Despite the presence of an activity calendar, the resident was not involved in any activities and required frequent redirection for safety due to restlessness and attempts to climb out of the wheelchair. Resident #31, with diagnoses including dementia and Alzheimer's disease, was observed sleeping or sitting passively without engagement in scheduled activities. Although music was played, there was no structured activity, and the resident did not respond to attempts at interaction. Staff confirmed that no activity personnel were present on the unit during certain shifts, and activities were limited to passive entertainment like music or TV. Resident #62, with severe cognitive impairment and sensory losses, was also observed sitting in front of a TV without engagement. Staff acknowledged the lack of individualized activities for residents with vision and hearing impairments and confirmed that activities were not consistently provided due to staffing shortages. The facility had not had a qualified Activity Director since early August, and the current staff lacked the necessary credentials in therapeutic recreational activities, further contributing to the deficiency.
Lack of Qualified Activity Director in Facility
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by regulations. The position description for the Activity Director outlined responsibilities including the development, implementation, supervision, and evaluation of activity programs tailored to meet the interests and well-being of each resident. However, interviews with staff revealed that the current activity staff lacked the necessary credentials in therapeutic recreational activities. Activity Staff A confirmed she did not possess the required qualifications, and Activity Supervisor Staff G admitted that no one in the department held the necessary credentials. The facility had been without a qualified Activity Director since early August, and the absence of qualified personnel affected the ability to conduct activities, particularly for residents in secured units. The Administrator acknowledged the deficiency, stating that the facility was actively seeking to hire a qualified Activity Director. Although a regional interim Activity Director was present for a week to oversee the program, this was not a permanent solution. The lack of qualified staff led to limited activity offerings, with staff unable to adhere to the activity calendar or provide individualized activities for residents with specific needs, such as those with vision and hearing impairments. The deficiency had the potential to impact all residents in the facility, as the activities program is integral to their physical, mental, and psychosocial well-being.
Failure to Conduct Proper Neurological Checks After Resident Fall
Penalty
Summary
The facility failed to ensure that nursing staff were competent in conducting neurological checks for a resident who experienced a fall with a head injury. The resident, a male with a history of multiple medical conditions including Type 2 Diabetes, Dementia, and Hypertension, was admitted on palliative care. After a fall, the resident complained of a headache and had a noticeable reddened spot on his head. Initial neuro checks showed a blood pressure of 161/96, which later dropped significantly to 100/50. However, the Licensed Practical Nurse (LPN) did not complete the neuro checks, as she documented the resident as asleep and did not want to wake him, failing to check pupil reaction and hand grasp. The LPN did not recognize the drop in blood pressure as significant and did not take further action. The resident was later found with no vital signs. The facility did not have a policy for completing neuro checks, and the Director of Nursing confirmed that neuro checks were not completed as required. The Director also stated that residents with head injuries should be awakened to complete neuro checks, which was not done in this case.
Failure to Provide Timely Notice of Non-Coverage
Penalty
Summary
The facility failed to provide two residents with the required Skilled Nursing Advanced Beneficiary of Non-Coverage form (CMS-10123) to inform them of potential liability for payment and their right to appeal. According to the facility's policy, this notice should be given at least two days before the end of a Medicare-covered Part A stay or when all Part B therapies are ending. However, for Resident #48, the last covered day of Part A service was on 2/29/24, but the durable power of attorney signed the form on 3/13/24. Similarly, for Resident #220, the last covered day was on 05/15/24, and the form was signed on 5/20/24. There was no documentation indicating that either resident received the notice prior to the end of their services. During an interview, Staff K, the social worker program manager, admitted that the process involved giving notice via regular mail, not certified mail, and there was no documentation of when the notice was sent. Staff K also mentioned that notice was provided verbally, but again, there was no documentation to confirm that this was done within the required timeframe of two days prior to the end of service. This lack of documentation and adherence to the facility's policy resulted in the deficiency noted in the report.
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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