Harborview Health Center West Altamonte
Inspection history, citations, penalties and survey trends for this long-term care facility in Altamonte Springs, Florida.
- Location
- 1099 West Town Parkway, Altamonte Springs, Florida 32714
- CMS Provider Number
- 105843
- Inspections on file
- 26
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Harborview Health Center West Altamonte during CMS and state inspections, most recent first.
The facility failed to implement and document an effective QAPI program, as required by its policy. The NHA reported having no participation in QAPI meetings, and the DON, in place since the prior year, acknowledged concerns with lack of notification of changes in condition, incomplete and inaccurate baseline care plans, incomplete comprehensive care plans that omitted respiratory care, and incomplete or inaccurate medical records, with no active PIPs addressing these issues. Review of QAPI records showed multiple PIPs initiated for change‑in‑condition notification, risk management events, documentation, and care plans, including one started after a resident’s representative was not informed of a hospital transfer following cardiac arrest, but none had supporting documentation, end dates, or evidence of monitoring or evaluation.
Two residents experienced significant changes in condition without timely notification to their representatives and, in one case, the physician. One cognitively impaired resident with multiple serious diagnoses suffered a cardiac arrest; staff initiated CPR, called 911, and transferred her to the hospital, but documentation showed only the resident herself was listed as notified, and her healthcare proxy later reported she was never contacted by the facility and learned of the event from the hospital. Another cognitively intact respite resident developed skin tears to the arm and leg, reportedly related to an outing incident, which were documented on CNA task lists but not reflected in nursing progress notes or the discharge summary; his daughter discovered a bandage at pickup and stated she was never informed of the incident or injuries despite attempts to reach facility leadership. The DON acknowledged that a change in condition should have been documented and that the nurse, MD, and family should have been notified, contrary to the facility’s own change-in-condition policy.
Two residents with significant respiratory conditions, including acute and chronic respiratory failure, COPD, CHF, and documented oxygen dependency, were admitted and readmitted with orders for continuous or PRN oxygen and multiple respiratory treatments, yet their baseline care plans did not address respiratory status, oxygen therapy, or individualized interventions such as head-of-bed elevation, monitoring, or reminders not to remove oxygen devices. One cognitively impaired resident’s family member reported finding the resident without a nasal cannula and with the bed flat despite continuous oxygen needs and stated she never received a copy of the initial plan of care or met with staff about respiratory concerns. Facility leadership confirmed that baseline care plans were incomplete, lacked respiratory focuses and interventions, and that policy required development of a comprehensive baseline care plan within 48 hours of admission and provision of a written summary to the resident or representative.
A resident with end stage liver disease, hepatocellular carcinoma, CHF, COPD, diabetes, and hypertension required oxygen therapy per physician and pulmonary specialist orders, including specific LPM ranges and directions to maintain SpO2 above 92% and use oxygen at night. Facility records showed ongoing oxygen use and weekly tubing changes, but no corresponding comprehensive care plan for oxygen therapy was developed. The resident was observed on oxygen via nasal cannula at 5 LPM, above the ordered 2–4 LPM PRN, and an RN reported that the resident or her son sometimes adjusted the flow rate. The DON and MDS Coordinator both confirmed the absence of an oxygen care plan despite daily order review and a policy requiring care plans for all services identified in the comprehensive assessment.
Two residents experienced incomplete and inconsistent clinical documentation related to significant changes in condition and skin injuries. One resident with multiple serious comorbidities had a code blue event where staff accounts conflicted regarding who found the resident, the resident’s condition before becoming unresponsive, who was present during CPR, and who made emergency calls; the medical record lacked key details such as time of event, condition prior to arrest, and identity of the person who found the resident. Another resident admitted for respite care with a history of stroke and a heel pressure ulcer reportedly sustained arm and leg injuries during an outing, as described by the resident and his daughter, while CNA notes later recorded skin tears to the arm and leg as “not new,” but there was no corresponding nursing assessment, change-in-condition documentation, provider or family notification, wound identification, treatment orders, or wound treatments recorded, and the discharge summary stated there were no skin issues.
A resident with cognitive intactness and physical impairments suffered second-degree burns after a CNA improperly microwaved noodles, leading to a spill. The facility lacked a clear policy and staff education on food reheating, contributing to the incident. The resident was transferred to a specialized burn unit for treatment.
A resident suffered second-degree burns after hot soup spilled on her, and the facility failed to conduct a thorough assessment and provide timely treatment. The LPN only noted a skin tear and did not perform a head-to-toe assessment, missing burns on the resident's arm, abdomen, and thigh. The resident was later hospitalized for five days. Additionally, another resident's pressure wound treatment lacked a physician's order and proper documentation.
A resident with hemiplegia and diabetic neuropathy suffered burns after a CNA reheated noodles in a microwave, contrary to facility policy. The facility lacked specific guidance and training for staff on reheating food, and no thermometers were available to check food temperatures. The incident highlighted a communication gap between the administrative team and staff regarding food safety procedures.
The facility failed to maintain resident dignity during meal assistance, as staff were observed standing while feeding residents and using the term 'feeders.' One resident was left to eat with her hands until her daughter intervened, despite previous concerns raised. Staff admitted to being in a hurry and using inappropriate language, contrary to facility policy.
The facility failed to complete and update PASARR Level I evaluations for two residents. One resident was readmitted with multiple diagnoses, including mental health conditions, but the PASARR did not list any mental illness. Another resident's PASARR was outdated and inaccurate, not reflecting current mental illness diagnoses despite evident behaviors and conditions. The DON acknowledged the oversight and lack of communication in ensuring PASARRs were completed and updated as per facility policy.
A resident with multiple health issues, including an unhealed pressure ulcer, did not receive weekly skin sweeps as ordered by the physician. Despite signatures on the MAR indicating acknowledgment of the order, documentation showed that skin sweeps were only conducted twice. Interviews with staff revealed inconsistencies in the execution and documentation of the skin sweeps, leading to a deficiency in care.
A resident with COPD was not provided respiratory therapy as per physician orders, with the oxygen concentrator set incorrectly and the nasal cannula not in use. The LPN mistakenly believed the order was for as-needed oxygen, leading to a lapse in care. The Unit Manager and DON confirmed the expectation for nurses to verify orders each shift.
A resident with multiple pressure ulcers received wound care without proper infection control practices. The Wound Care nurse performed the procedure alone, despite the resident's inability to reposition herself, leading to potential cross-contamination. The ADON confirmed that proper assistance should have been ensured to prevent infection.
Two residents were found with inaccessible call devices, preventing them from calling for staff assistance. One resident's call device was placed on a nightstand out of reach, while another's was tangled in the bed frame. CNAs later repositioned the devices within reach, aligning with the facility's policy for call light accessibility.
Two residents in an LTC facility did not receive showers as scheduled or according to their preferences. One resident, with severe cognitive impairment, only received two showers over three months, with no documentation of refusals. Another resident, with moderate cognitive impairment, had a grievance filed for morning showers but continued to receive them in the evening. The facility's policy on person-centered care was not followed, leading to deficiencies.
Failure to Implement and Document an Effective QAPI Program
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective, comprehensive, data‑driven Quality Assurance and Performance Improvement (QAPI) program as required by its own policy. During an interview, the Nursing Home Administrator (NHA), who had been in the role for only two days, reported he had not participated in any QAPI meetings. The DON, who had been in her role since June 2025, acknowledged concerns related to lack of notification of changes in condition for residents, incomplete and inaccurate baseline care plans, incomplete comprehensive care plans that did not include respiratory care, and incomplete or inaccurate medical records. She stated she was not aware of these concerns and that there were no active Performance Improvement Plans (PIPs) addressing them, despite the facility’s process of bringing departmental concerns from morning clinical meetings to monthly QAPI meetings for discussion and PIP development. Record review showed that several PIPs had been initiated in 2025 without supporting documentation, end dates, or evidence of monitoring. A PIP started in January 2025 for notification of changes in condition followed an incident in which a resident’s representative was not informed that the resident had been transferred to the hospital after a cardiac arrest, but there was no documentation of what actions were taken or how they were monitored. Additional PIPs were noted for risk management events in April 2025, documentation in September 2025, and care plans and baseline care plans in June 2025, all lacking corresponding documentation of implementation or evaluation. This was confirmed by the NHA. Review of the facility’s QAPI policy, revised in August 2025, showed that the facility was required to maintain documentation demonstrating an ongoing QAPI program, including data collection and analysis, and documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities, which was not reflected in the records reviewed.
Failure to Notify Representatives and Physicians of Significant Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify residents’ representatives and physicians of significant changes in condition for two residents. For the first resident, an elderly woman with severe cognitive impairment and multiple serious diagnoses including metabolic encephalopathy, dysphagia, diabetes, sepsis, congestive heart failure, acute kidney failure, adult failure to thrive, COVID-19, pneumonia, and acute respiratory failure, the record showed she required a surrogate for decision-making. On the identified date, she was found unresponsive and in cardiac arrest. Staff initiated CPR, called 911, obtained a physician’s order to transfer her to the emergency room, and completed a transfer and discharge form. However, the form listed the resident herself as the responsible party notified, using her own phone number, and there was no documentation that any emergency contacts or her healthcare proxy were notified of this critical change in condition and transfer. Interviews further clarified the lack of appropriate notification for this resident. An RN who assisted with CPR stated that during the code, the Nurse Supervisor was at the desk calling 911, the physician, and the family, and later the former DON informed the nurses that the resident’s daughter was upset because she had not been notified of her mother’s transfer. The daughter, identified in the record as the healthcare proxy and listed as emergency contact #1, reported she was not contacted by the facility and only learned of her mother’s cardiac arrest and transfer when the hospital called her later that evening. She stated she told the former DON she was upset about not being notified and was told that staff had mixed up the phone numbers, but she never received an explanation or follow-up. The former DON confirmed that the assigned nurse reported confusing the phone numbers and acknowledged that no investigation was conducted after the incident, and that the family was only made aware of the transfer when the granddaughter called the facility after the resident had already been transferred. The second resident was admitted for respite care with diagnoses including stroke with right-sided deficit, a right heel pressure ulcer, coronary artery disease, and a pacemaker, and was documented as cognitively intact. Initial assessments and daily nursing documentation indicated no skin issues, while CNA task lists later documented a skin tear to the arm and then a skin tear to the leg on subsequent days. The physician’s history and physical noted right heel pain but did not mention arm or leg skin tears, and the discharge summary stated there were no skin issues at discharge. The resident’s daughter reported that when she arrived to pick him up, she observed a bandage on his leg and was told by the resident that wheelchairs had fallen during an outing, causing scratches to his arm and a gash to his leg. She stated that no one from the facility had called to inform her of the incident or the resulting skin impairments, despite her multiple calls to the Administrator and a conversation with the Social Worker. The DON later stated there should have been a documented change in condition for the skin tears and confirmed that the nurse, physician, and daughter should have been notified. The facility’s policy on Change in a Resident’s Condition or Status required prompt notification of the resident, attending physician, and representative of changes in medical or mental condition or status, including incidents, accidents, injuries, and transfers, which was not followed in these cases.
Failure to Implement Respiratory-Focused Baseline Care Plans and Provide Plan Summaries
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement effective, person-centered baseline care plans within 48 hours of admission for residents with significant respiratory needs, and failure to provide a required written summary of the baseline care plan to a resident’s representative. For one resident with severe cognitive impairment, acute respiratory failure, COVID-19, pneumonia, CHF exacerbation, and continuous oxygen orders, the baseline care plan created at readmission did not address respiratory needs or continuous oxygen therapy. The plan was largely blank except for behavior and diet comments, and did not include individualized interventions such as maintaining the head of bed elevation or reminders not to remove the nasal cannula, despite these needs being documented in transfer forms and physician orders. The same resident’s daughter reported that the resident required continuous oxygen, preferred to have the head of bed elevated to breathe better, and needed reminders not to remove her nasal cannula due to confusion. She stated that on several visits she found the resident without the nasal cannula and with the head of the bed flat, and that staff were not consistently communicating about the resident’s preferences and comfort needs. The daughter also confirmed she never received a copy of the initial plan of care and had not met with anyone at the facility regarding her concerns about her mother’s respiratory status, contrary to facility policy requiring that a written summary of the baseline care plan be provided to and signed by the resident or representative. For a second resident with a history of end stage renal disease on dialysis, cardiac arrest, CHF, acute and chronic respiratory failure, COPD, colostomy, and hypertension, hospital records documented chronic respiratory failure and oxygen dependency, and the resident returned with a primary diagnosis of acute respiratory failure. Physician orders included three respiratory inhalers, and nursing notes and vital signs documented oxygen use on multiple dates. However, both the admission and readmission baseline care plans did not address the resident’s respiratory status, respiratory medical conditions, or chronic oxygen use. The MDS Director and DON acknowledged that respiratory assessments, care plan focuses, and interventions such as oxygen use, monitoring, head of bed elevation, and observation for respiratory distress should have been included, and that the baseline care plan form, even before modification, allowed for documentation of such needs.
Failure to Develop and Implement Oxygen Therapy Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing oxygen use for a resident who required oxygen therapy. The resident was admitted with multiple diagnoses including end stage liver disease, hepatocellular carcinoma, diastolic congestive heart disease, COPD, diabetes, and hypertension. An admission MDS showed the resident required oxygen therapy, was cognitively intact with a BIMS score of 15/15, and needed full assistance with toileting, hygiene, and transfers. Physician orders documented oxygen use beginning with 2 LPM as needed, then 1 LPM, and later 2–4 LPM as needed to maintain oxygen saturation greater than 92%. Pulmonary physician progress notes further directed staff to monitor oxygen saturation, titrate oxygen as needed, and provide supplemental oxygen as needed to maintain saturation above 92% and at night while sleeping. The Treatment Administration Record showed weekly oxygen tubing changes starting in late December, and nursing documentation recorded ongoing oxygen use at various flow rates. Despite these documented needs and orders, review of the resident’s care plan revealed there was no care plan for oxygen use. On observation, the resident was found in bed wearing a nasal cannula connected to an oxygen concentrator set at 5 LPM, although the current order was for 2–4 LPM as needed. The resident reported using oxygen due to shortness of breath, liver cirrhosis with frequent fluid removal from the abdomen, COPD, and fatigue limiting her mobility. An RN confirmed the concentrator was set at 5 LPM, acknowledged the order was for 2–4 LPM as needed, and stated that the resident or her son sometimes changed the oxygen rate. The DON confirmed the resident used oxygen per physician orders and acknowledged there was no oxygen care plan but that there should have been one. The MDS Coordinator, who reviewed physician orders daily, also confirmed there was no care plan for oxygen use and stated that the orders must have been missed, despite the facility’s policy requiring a comprehensive person-centered care plan including all services identified in the comprehensive assessment.
Incomplete and Inconsistent Clinical Documentation for Change in Condition and Skin Injuries
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and consistent clinical records for two residents, affecting the reliability of the medical record and continuity of care. For the first resident, who had multiple serious diagnoses including metabolic encephalopathy, dysphagia, diabetes, sepsis, congestive heart failure, acute kidney failure, and adult failure to thrive, staff accounts of a code blue event were inconsistent and incompletely documented. An LPN working the night shift reported being told that an unidentified CNA found the resident unresponsive, that this was reported to the second-shift Nurse Supervisor, and that EMS transported the resident to the hospital. An RN who participated in the code stated she heard the assigned nurse calling for help, found the resident unresponsive with the assigned nurse performing CPR, and reported that only she and the assigned nurse were in the room while the Nurse Supervisor made calls to 911, the family, and the physician. The former DON later reported being informed of the code blue the next morning and recounted a different version from the assigned nurse, stating the nurse had gone in to check the resident’s blood sugar, found the resident with Cheyne-Stokes breathing, stayed at the bedside until the resident became unresponsive, and then called a code blue. In this account, the second-shift Nurse Supervisor was the only other person in the room during CPR, and the assigned nurse made the calls to 911, the physician, and the family. Review of the resident’s medical record showed a change in condition note indicating the resident was found unresponsive and had a cardiac arrest, that CPR was initiated, 911 was called, and a transfer to the emergency room was ordered. However, the documentation lacked a specific time of the event, did not identify who found the resident, and did not describe the resident’s condition prior to becoming unresponsive, contrary to the facility’s documentation policy requiring a complete and accurate representation of the resident’s experiences. For the second resident, admitted for respite care with a history including stroke with right-sided deficit, right heel pressure ulcer, coronary artery disease, and a pacemaker, the facility failed to document an incident and resulting skin impairments. The resident’s daughter reported that when she arrived to pick him up at discharge, she observed a bandage on his leg and was told by the resident that he had gone on an outing where unsecured wheelchairs fell on the way back, scratching his arm and causing a gash in his leg; she stated no one from the facility informed her of these new wounds or the incident. CNA documentation showed the resident refused group activities on two specific dates and contained skin observation entries noting a “not new” skin tear to the arm on one date and a “not new” skin tear to the leg on another, with no skin observation documentation for several intervening days. The treatment administration record and physician orders contained no wound identification or treatment orders for the relevant period, and progress notes and admission assessments documented skin as fair, warm, and dry, with no skin issues noted. There was no documentation of a change in condition, no nursing assessment of the reported wounds, no provider or family notification, and the discharge summary stated there were no skin issues at discharge, despite the CNA skin observation entries and the daughter’s report of a leg wound with a bandage.
Resident Suffers Burns Due to Improper Food Handling
Penalty
Summary
The facility failed to prevent an avoidable accident involving a resident who suffered second-degree burns due to the improper handling of microwaved food. The incident involved a resident with left-sided hemiplegia and hemiparesis, type 2 diabetes mellitus with diabetic neuropathy, and a contracture of the left hand. The resident was cognitively intact and required setup assistance for eating. On the day of the incident, a CNA prepared a cup of noodles for the resident using a microwave, which was not in accordance with the facility's policy that required food to be heated in the kitchen. The hot liquid from the noodles spilled on the resident, causing burns to her left arm, hand, abdomen, and thigh. The facility lacked a clear policy and staff education regarding the heating and reheating of resident food, which contributed to the incident. The CNA who prepared the noodles was unaware of any in-service training related to food reheating, and the facility's administration had not ensured that all staff were educated on this matter. The Administrator acknowledged that microwaves should not have been available on the unit and that there was a previous discussion about reheating food due to a grievance, but no formal education was provided to the staff. Following the incident, the resident's daughter called 911, and the resident was transferred to a hospital and then to a specialized burn unit. The facility's documentation and response to the incident were inadequate, as the resident's wet clothes were not removed promptly, and there was a lack of thorough assessment and documentation by the nursing staff. The facility's failure to implement and educate staff on proper food handling procedures resulted in actual harm to the resident.
Failure to Provide Timely Burn Assessment and Treatment
Penalty
Summary
The facility failed to provide immediate and thorough nursing assessment and treatment services related to burns for a resident, resulting in actual harm. The resident, who had left-sided hemiplegia and hemiparesis, type 2 diabetes mellitus with diabetic neuropathy, and a contracture of the left hand, suffered second-degree burns after hot noodle soup spilled on her. The incident occurred when a CNA heated the soup in a microwave and placed it on the resident's table, leading to the spill. The LPN who assessed the resident only noted a skin tear on the left hand and did not perform a comprehensive head-to-toe assessment, missing burns on the resident's left arm, abdomen, and thigh. The resident's daughter was informed of the incident and upon arrival at the facility, found her mother in pain and still in wet clothes. The daughter called 911, and the resident was taken to a hospital where she was assessed and subsequently transferred to a specialized burn unit. The hospital records indicated partial thickness burn wounds with blistering on multiple areas of the resident's body. The facility's failure to conduct a complete assessment and provide timely treatment led to the resident being hospitalized for five days. Additionally, the facility failed to obtain a physician's order for treatment and date a treatment dressing for another resident with a pressure wound. An undated treatment bandage was observed on the resident's right forearm, and upon review, it was found that there was no physician's order for the treatment. The facility's policy required evidence-based treatments in accordance with physician orders, which was not followed in this case.
Lack of Food Reheating Policy Leads to Resident Burns
Penalty
Summary
The facility failed to provide a policy or training to staff regarding the reheating of food for residents, which resulted in a resident receiving second-degree burns. The incident involved a resident with left-sided hemiplegia, type 2 diabetes mellitus with diabetic neuropathy, and a contracture of the left hand. The resident requested a cup of noodles from the facility's Activity Store, which a CNA heated in a microwave located in the staff kitchen on the unit. As the CNA placed the noodles on the resident's over-bed tray table, the resident accidentally knocked the cup, causing the hot noodles to spill and burn her. Interviews with staff and a review of facility policies revealed that there was no specific guidance or training provided to staff on the safe reheating of food for residents. The Administrator and former DON acknowledged that there was a discussion about not heating or reheating resident food, but it was only discussed with the Administrative team and not communicated to the staff. Additionally, there were no thermometers available in the unit kitchens for staff to check food temperatures, and the staff did not receive any education on this matter until after the incident occurred.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat residents with dignity and care, as evidenced by staff standing while feeding residents and referring to them as 'feeders.' On one occasion, a CNA was observed standing over a resident while feeding her, acknowledging that she was aware of the importance of sitting at eye level but was too busy to get a chair. Additionally, the same resident was left unattended with her meal tray, leading her to eat with her hands until her daughter arrived to assist. The daughter expressed concerns about the lack of assistance her mother received during meals, despite having previously raised these issues with the facility. Another incident involved a CNA standing while feeding a different resident, citing being in a hurry as the reason. The CNA admitted to using the term 'feeder' aloud in the hallway to identify residents needing meal assistance. The facility's policy emphasized the importance of treating residents with dignity, including using respectful language and ensuring staff are informed about residents' needs. The DON and Unit Manager confirmed that staff should not use the term 'feeder' and should be familiar with residents' needs before delivering meal trays.
Failure to Complete and Update PASARR Evaluations
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level I evaluation was completed for two residents. Resident #33 was readmitted to the facility from the hospital with multiple diagnoses, including cerebral infarction, aphasia, vascular dementia, major depressive disorder, and mood disorder. Despite these conditions, the PASARR Level I evaluation dated 10/25/23 did not list any mental illness diagnoses. The Director of Nursing (DON) acknowledged that a new PASARR should have been completed upon the resident's readmission, but it was not done due to a lack of communication between the Admissions office and the DON. Resident #65 was admitted with diagnoses including chronic atrial fibrillation, type 2 diabetes, dementia, major depressive disorder, and mood disorder. The resident's PASARR Level I screen dated 5/23/22 was found to be inaccurate as it did not list any mental illness diagnoses, despite the resident's care plan and medical records indicating behaviors and conditions associated with mental illness. The DON and Assistant DON confirmed the PASARR was inaccurate and had not been updated to reflect the resident's current diagnoses. The facility's policy required PASARR Level I to be completed prior to admission and updated if new diagnoses arose, which was not adhered to in these cases.
Failure to Conduct and Document Weekly Skin Sweeps
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice to prevent pressure ulcers for a resident. The resident, a male with multiple diagnoses including heart failure, diabetes, and prostate cancer, was at risk for pressure ulcers and had an unhealed pressure ulcer classified as an unstageable deep tissue injury. A physician's order required weekly skin sweeps to be conducted every Wednesday on the 7 AM-3 PM shift. However, documentation revealed that skin sweeps were only conducted on two occasions, and no other documentation could be identified to confirm that the weekly skin sweeps were performed as ordered. Interviews with facility staff, including an LPN, the Unit Manager, the Assistant Director of Nursing, and a Registered Nurse, revealed inconsistencies in the documentation and execution of the skin sweeps. The staff acknowledged the lack of documentation for the skin sweeps despite signatures on the Medication Administration Record (MAR) indicating acknowledgment of the order. The facility's policy required a full body skin assessment upon admission and weekly thereafter, but the failure to document and perform the weekly skin sweeps as ordered led to the deficiency.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to provide respiratory therapy as per physician orders for a resident with chronic obstructive pulmonary disease (COPD) and other health conditions. The resident was observed without the prescribed nasal cannula for oxygen, and the oxygen concentrator was set at 1.5 liters per minute instead of the ordered 1 liter per minute. The resident stated she rarely used the oxygen, and the assigned nurse, LPN F, incorrectly believed the order was for oxygen as needed. Upon verification, LPN F acknowledged the error and corrected the oxygen flow rate. The Unit Manager and Director of Nursing confirmed that the expectation was for nurses to check and verify oxygen orders on all shifts. The facility's Oxygen Administration Policy required oxygen to be administered under physician orders, except in emergencies. The failure to follow the physician's orders for continuous oxygen at the correct flow rate was acknowledged by the nursing staff, indicating a lapse in adherence to the established protocol.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care for a resident with multiple pressure ulcers. The resident, who was readmitted from the hospital with conditions including cerebral infarction, vascular dementia, and multiple pressure ulcers, was observed receiving wound care on the right buttock. The Wound Care nurse performed the procedure without a second person to assist, despite the resident's inability to reposition herself due to severe cognitive impairment and limited mobility. The nurse attempted to maintain a clean environment but acknowledged the difficulty in doing so without assistance. The Assistant Director of Nursing, who also serves as the Infection Preventionist, confirmed that the Wound Care nurse should have ensured proper assistance was available to prevent cross-contamination. The facility's policy on clean dressing changes emphasizes the importance of preventing infection and cross-contamination, which was not fully adhered to in this instance. The nurse's actions, including handling the resident and wound supplies without a second person, contributed to the deficiency in infection control practices.
Inaccessible Call Devices for Residents
Penalty
Summary
The facility failed to provide accessible call devices for two residents, leading to a deficiency in ensuring residents could call for staff assistance. Resident #30, who was alert and oriented, was observed with a call device placed on a nightstand out of her reach. She expressed a desire to get out of bed and into her wheelchair but had no means to contact staff for help. A CNA later confirmed the inaccessibility of the call device and repositioned it within the resident's reach, educating her on its use. Similarly, Resident #55, also alert and oriented, had a call bell device that was wound up in the bed frame and out of reach. The resident attempted to use the call bell but was unable to reach it. A CNA verified the issue and adjusted the call light to be within the resident's reach. The facility's policy requires call lights to be within hand's reach for all residents, and the DON emphasized the availability of special call lights for residents with difficulty using standard devices.
Failure to Provide Scheduled Showers and Honor Resident Preferences
Penalty
Summary
The facility failed to provide scheduled showers and accommodate resident preferences for two dependent residents. Resident #1, a 72-year-old male with severe cognitive impairment and multiple health conditions, was scheduled for showers twice a week but only received them twice over a three-month period. There was no documentation of shower refusals or adjustments to his care plan to reflect any changes in preference. The Director of Nursing acknowledged the lack of documentation and confirmed that showers were not provided as scheduled. Resident #5, an 82-year-old female with moderate cognitive impairment and other health issues, was also not provided showers according to her preference. Despite a grievance filed by her responsible party requesting morning showers, the resident continued to receive showers in the evening. Documentation showed inconsistencies, with some showers not recorded in the Point of Care system. The Assistant Director of Nursing could not explain the discrepancies, and the Unit Manager confirmed awareness of the grievance but noted that the resident's preferences were not honored. The facility's policy on Activities of Daily Living emphasizes person-centered care and honoring resident preferences, yet this was not adhered to in the cases of Residents #1 and #5. The lack of proper documentation and failure to accommodate resident preferences led to the identified deficiencies in care.
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Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
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