Kissimmee Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kissimmee, Florida.
- Location
- 2511 John Young Parkway North, Kissimmee, Florida 34741
- CMS Provider Number
- 106011
- Inspections on file
- 30
- Latest survey
- February 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Kissimmee Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Two residents with severe cognitive impairments experienced falls due to inadequate care plans and supervision. One resident, dependent on staff for daily activities, had multiple falls without necessary interventions like frequent checks. Another resident's care plan included a dycem to prevent sliding from a wheelchair, but it was not consistently used, leading to falls. The facility failed to update care plans and ensure staff were informed of necessary interventions.
The facility failed to implement comprehensive care plans for two residents. One resident's care plan required padded bed rails for safety, but they were unpadded during the day. Another resident, who primarily spoke Spanish, had no communication plan addressing her need for an interpreter, leading to a medication error and distress. The facility's policy emphasizes person-centered care plans, but these were not adequately developed for the residents' needs.
A resident with type 2 diabetes experienced severe pain and did not receive timely medication. When the RN administered the medication, it was not documented in the MAR, and the resident's pain level was not assessed. Facility policies require accurate documentation, which was not followed, resulting in a deficiency.
A CNA in a facility referred to a resident requiring assistance with eating as a "feeder," which was acknowledged by the DON as a dignity issue. This terminology was used despite the facility's policy on promoting resident dignity and the CNA's competency in maintaining patient self-worth. The resident had a severe condition, as indicated by a low assessment score.
The facility failed to maintain communication with an external center for a resident's care, lacking documentation and follow-up on the resident's condition. Additionally, the facility did not provide appropriate activities for another resident with visual limitations, offering materials that did not meet their needs.
A resident at an LTC facility experienced neglect when a nurse attempted to administer a discontinued medication and placed a dropped pill back in the cup. The resident, who primarily spoke Spanish, reported the incident to the MDS Coordinator, but the facility failed to report the allegations to the State Agency and protect the resident during the investigation. The Director of Nursing and the nurse involved allegedly yelled at the resident, and the nurse was reassigned to the resident despite her request for a different caregiver.
A facility failed to promote dignity in dining for a resident who required assistance with eating. A CNA referred to the resident as a "feeder," a term acknowledged by the DON as a dignity issue. Despite passing required competencies, the CNA's language did not align with the facility's policy on resident dignity.
A facility failed to notify a resident's emergency contact and POA of a medication change. The resident, unable to make healthcare decisions, was discharged with specific medication orders, which were altered by the facility's physician without informing the resident's son, the healthcare surrogate. This affected the resident's alertness and participation in activities. The Unit Manager admitted the oversight, and there was no documentation of notification, violating the resident's right to be informed.
A resident with intact cognition was left unsupervised with a medication cup containing various pills, without a documented plan for self-administration. RN D admitted to leaving the medications with the resident, contrary to facility policy, which requires supervision during medication administration. The facility's policy mandates an interdisciplinary team evaluation for safe self-administration, which was not conducted.
A resident reported a medication error and mistreatment by staff, including a nurse attempting to administer a discontinued medication and placing a dropped pill back in a cup. The resident, who primarily spoke Spanish, faced communication barriers and alleged that the DON and nurse yelled at her. Despite reporting the incident to the MDS Coordinator and DCF, the facility failed to report the allegations to the State Agency and did not protect the resident during the investigation.
A facility failed to accurately document a major injury in a resident's MDS assessment. The resident, who had been readmitted from a hospital, reported breaking a bone after a fall. The MDS Transitional Nurse acknowledged the error, despite reviewing hospital documentation. The facility's policy requires accurate assessments, which was not followed.
The facility failed to implement comprehensive care plans for two residents. One resident's care plan specified padded bed rails for safety, but they were not in place, and staff were unaware of the requirement. Another resident, whose primary language was Spanish, did not have a communication care plan addressing her need for an interpreter, leading to a distressing medication incident. The facility's policy on person-centered care plans was not followed, resulting in deficiencies.
Two residents with severe cognitive impairments experienced falls due to the facility's failure to revise and implement appropriate care plan interventions. One resident suffered a hematoma after multiple falls, while another fell from a wheelchair due to the absence of a dycem. The care plans lacked necessary supervision measures, and staff were not adequately informed of changes, leading to repeated incidents.
A resident with visual impairment was not provided with suitable activities, receiving regular print materials instead of large print, leading to frustration and lack of engagement. The facility's assessment indicated the need for activities compatible with the resident's capabilities, which was not met.
A facility failed to maintain communication with an external treatment center for a resident receiving specific services. The resident's medical record lacked documentation of communication between the facility and the center. Staff interviews revealed that a communication binder previously used had not been utilized for over six months, and the center's staff faced challenges in contacting the resident's nurse. The ADON confirmed the absence of necessary documentation, highlighting a lapse in communication practices.
A resident with type 2 diabetes experienced severe pain and was given medication by an RN, but the administration was not documented in the MAR. The facility's policies require accurate documentation of all services provided, which was not followed in this case, as emphasized by the Unit Manager and DON.
The facility failed to maintain effective communication with hospice services, resulting in inadequate care for two residents. One resident experienced multiple falls and changes in condition without timely notification to hospice, while another resident's fall and subsequent pain were not communicated, leading to a delayed hospital transfer. The facility's policies and agreements with hospice providers were not followed, impacting the coordination of care.
An RN in an LTC facility failed to sanitize a portable monitoring device between its use on two residents during medication administration. The RN admitted to forgetting the procedure due to stress. The facility's IP confirmed that staff had been trained to use purple top wipes for sanitizing equipment, but the RN had not signed the recent in-service training. The DON emphasized the importance of cleaning equipment between uses to prevent cross-contamination.
The facility failed to monitor antibiotic use as required by their stewardship program. Several residents were prescribed antibiotics without proper follow-up testing or inclusion in the Control Report. The ADON/IP admitted to not analyzing prescribing trends or ensuring all residents on antibiotics were tracked, violating the facility's surveillance policy and stewardship commitment.
The facility failed to maintain its fire alarm system according to NFPA 101 standards, as evidenced by the lack of documentation for the annual air flow testing of duct detectors. During a record review and interview, the Maintenance Director acknowledged the absence of this critical testing, indicating non-compliance with NFPA 101 and NFPA 72 codes.
A resident admitted for respite care with brain cancer, cachexia, and quadriplegia did not receive proper care as per physician orders. The facility failed to administer and document Midodrine HCl for hypotension and did not monitor vital signs or check PEG tube residuals as required. The DON confirmed these omissions without providing an explanation.
The facility failed to provide adequate pressure ulcer care for three residents, resulting in incorrect or missing treatments. A resident with a stage 3 ulcer did not receive prescribed treatments due to lack of documentation. Another resident with a stage 4 ulcer was given incorrect ointment and lacked necessary supplements. A third resident received the wrong type of dressing, missing antimicrobial properties. These deficiencies highlight a failure in following wound care orders.
Failure to Implement Adequate Care Plans and Supervision
Penalty
Summary
The facility failed to revise and implement appropriate interventions for two residents, leading to deficiencies in their care. Resident #3, who had severe cognitive impairment, hearing loss, and vision issues, experienced multiple falls. Despite being dependent on staff for various activities, the care plan did not include necessary interventions such as frequent checks or appropriate supervision. The resident's care plan was not updated to reflect her need for constant supervision, and interventions like offering toileting after meals were not implemented. The resident's daughter expressed concerns about the lack of supervision and the resident's tendency to attempt activities independently, which were not adequately addressed by the facility. Resident #51, who also had severe cognitive impairment and required substantial assistance for daily activities, experienced falls in the facility's TV room. The care plan included the use of a dycem to prevent sliding from the wheelchair, but it was not consistently used or documented in the resident's care plan. Staff were unaware of the dycem's absence, and the resident's care plan did not reflect the need for increased supervision during times of behavioral changes. The facility's failure to ensure the dycem was used and to provide adequate supervision contributed to the resident's falls. The facility's policies on accidents and supervision, as well as comprehensive care plans, were not effectively implemented. The guidelines required communication and documentation of interventions across all disciplines, but this was not done. The care plans for both residents lacked necessary interventions, and staff were not adequately informed of their responsibilities. The facility's failure to update care plans and ensure staff were aware of and implemented necessary interventions led to the deficiencies observed.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: New risk evaluations were completed for Resident #51 to reflect accurate information, and their care plans and Kardex's were updated to reflect accurate risk assessments, with appropriate and individualized prevention interventions implemented. Resident #3 is no longer residing at the facility. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents who have had a have the potential to be affected. The MDS Coordinator and Unit Managers conducted a facility-wide audit of risk assessments and care plans for residents with a score of 12 or less to identify any discrepancies. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Direct Care staff (RNs, LPNs, and C.N.A.S) staff will receive mandatory training regarding review and use of Care Plan/Kardex prior to providing care to Residents. This education will also be completed upon hire and at least annually. All Direct Care staff will be in-service by. Any Direct Care staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Direct Care staff will be in-service by the ADON during their orientation. Starting on all Licensed nurses (RNs and LPNs) and MDS staff on the proper completion of risk assessments, individualized care planning, and the importance of ensuring interventions are documented in the Kardex. All Licensed nurses (RNs and LPNs) and MDS staff will be in-service by. Any Licensed nurses (RNs and LPNs) and MDS staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Licensed nurses (RNs and LPNs) and MDS staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing or Designee will review a sample of five residents risk evaluations, care plans and Kardexs weekly for four weeks, then monthly for three months to ensure continued compliance. Any discrepancies identified will be corrected immediately, and trends will be addressed through additional staff training or process adjustments. Findings will be reported in the monthly QA/QAPI meeting for further review and action as needed for a minimum of 3 months. (e) Date of compliance
Deficiencies in Care Plan Implementation and Communication
Penalty
Summary
The facility failed to implement an individualized comprehensive care plan for a resident reviewed for safety precautions. The resident was admitted with diagnoses including fluid disturbances and speech issues. The Minimum Data Set (MDS) assessment indicated the resident was rarely or never understood. Despite the care plan specifying the use of padding on bed rails for safety, observations revealed the rails were unpadded during the day. A Certified Nursing Assistant (CNA) confirmed the absence of padding and was unaware of the reason. The Restorative Unit Manager stated the padding was only applied at night when the resident became agitated, contrary to the care plan's requirements. Another deficiency was identified for a resident reviewed for communication needs. This resident, who had intact cognition and primarily spoke Spanish, expressed a desire for an interpreter when communicating with healthcare staff. The MDS assessment noted her social isolation and dependence on staff for personal care. However, her care plan did not address her communication needs or preference for an interpreter. An interview with the resident revealed a recent incident where a nurse administered a discontinued medication and mishandled another medication, leading to distress. The resident preferred Spanish-speaking staff and had communicated this preference, but it was not reflected in her care plan. The facility's policy on comprehensive care plans emphasizes the development of person-centered plans that incorporate residents' personal and cultural preferences. Despite this, the care plans for both residents failed to address their specific needs as identified in their assessments. The MDS Coordinator acknowledged the oversight in the communication care plan and confirmed that the resident's preference for an interpreter was known but not documented in the care plan.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: For Resident #92, the pads were placed per the Resident's care plan. Resident #92 was reassessed to ensure all precautions were properly implemented. CNA Q was re-educated on the importance of following care plan interventions, especially for residents with. For Resident #56, the care plan was updated to reflect the resident's primary language of Spanish with the intervention of utilizing an interpreter as indicated. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents with a diagnosis of and Residents who do not speak English proficiently have the potential to be affected. A facility-wide audit of all residents with was conducted to ensure appropriate interventions were care planned and in place. MDS Coordinator conducted an audit of all residents with limited English proficiency to ensure their communication needs were appropriately care planned. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Nurse leadership team, including Director of Nursing, Assistant Director of Nursing, Unit Managers, and MDS Nurses received in-service training on by Regional Nurse on the requirement for comprehensive Resident Centered care plans with focus on Residents with and/or limited English proficiency. Starting on all Direct Care staff (RNs, LPNs, and C.N.A.S) will receive mandatory training on the importance of following individualized care plan interventions, ensuring safety interventions are in place for precautions per plan of care, and on communicating with Residents with limited English proficiency per plan of care to include use of Propio 1 Interpreter Line. All Direct Care staff will be in-service by. Any Direct Care staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Direct Care staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing or designee will conduct weekly audits of 5 Residents with or Limited English Proficiency for four weeks, then 10 monthly for at least three months, to ensure care plans are accurately implemented and followed. Any discrepancies found will result in immediate correction and staff re-education. Audit results will be reviewed in the facility's monthly Quality Assurance and Performance Improvement (QAPI) meetings. (e) The compliance date is.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to accurately document the administration of medications in the Medication Administration Record (MAR) for a resident. The resident, who was readmitted to the facility with diagnoses including type 2 diabetes, complained of severe pain rated at 10 out of 10. Despite informing the nurse, the resident did not receive medication promptly. When the Registered Nurse (RN) eventually administered the medication, she failed to document it in the MAR and did not assess the resident's pain level or location before administration. The facility's policies on charting and documentation, as well as medication administration, require that all services provided, including medications administered, be accurately documented in the resident's medical record. However, the RN did not document the administration of the medication or the resident's response to it. The Unit Manager and Director of Nursing both emphasized the importance of accurate documentation, which was not adhered to in this instance, leading to a deficiency in the facility's compliance with regulatory standards.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: Resident # 18 assessed for, No. Notified physician and advised to discontinue order. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents receiving medication have the potential to be affected. An audit was conducted for all current Residents receiving meds to ensure the assessment was completed and the medication administration was documented. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Nursing staff (RNs, LPNs) will receive mandatory Education for all nurses on accurately documenting of prn medications on the MAR. All Nursing staff will be in-service by. Any Nursing staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Nursing staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not reoccur: DON, Unit managers or designee will observe 2 nurses medication administration of 2 residents 3 times a week for 2 weeks then 2 nurse's medication administration for 2 residents once a week for (3) months to ensure compliance. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee. (e) The date of compliance is
Inappropriate Terminology Used by CNA Compromises Resident Dignity
Penalty
Summary
The facility failed to promote dignity in dining for a resident, as evidenced by the use of inappropriate terminology by a Certified Nursing Assistant (CNA). During an observation, the CNA referred to a resident who required assistance with eating as a "feeder," a term that was acknowledged by the Director of Nursing as a dignity issue. This terminology was used despite the facility's policy on promoting and maintaining resident dignity, which emphasizes treating each resident with respect and dignity. The resident in question had a severe condition, as indicated by a Minimum Data Set quarterly assessment score of 3 out of 15. The CNA had previously passed the required competencies for her job, which included maintaining and enhancing a patient's self-worth. However, the use of the term "feeder" was inconsistent with these competencies and the facility's policy, highlighting a failure to uphold the dignity and individuality of the resident.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: CNA H was counseled regarding the inappropriate [R], and provided immediate re-education on maintaining resident dignity and respectful communication. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents who require assistance during meals have the potential to be affected. Residents with a score of 12 and over were interviewed by the Social Services Staff and Administrator to determine if they have experienced or witnessed any undignified language or treatment. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on [date], all staff will receive mandatory training on resident rights, dignity, and person-centered communication, with a focus on respectful language. All staff will be in-service by [date]. Any staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired staff will be in-serviced by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing (DON) or designee will conduct 5 meal service audits weekly for 1 month, then 10 monthly for at least two additional months, to ensure staff are promoting dignity. Findings from audits will be reviewed in the facility's Quality Assurance and Performance Improvement meetings, and corrective actions will be taken as needed. Compliance monitoring will continue until sustained improvement is demonstrated, as determined by QAPI oversight. (e) Date of compliance: [date]
Deficiencies in Communication and Activity Program
Penalty
Summary
The facility failed to maintain ongoing communication and collaboration regarding the care and services for a resident receiving treatment at an external center. The resident's medical record indicated a moderate cognitive impairment, and the facility did not ensure consistent communication with the external center providing services. The Clinical Manager and Clinical Nurse from the center reported that a communication binder, previously used for documenting updates, had not been seen for over six months. Additionally, there was no consistent follow-up communication from the facility's nurses after each session to update the resident's condition. The Assistant Director of Nursing acknowledged the importance of such communication for coordinating care and confirmed the absence of documentation in the resident's medical record. The facility also failed to provide an ongoing program of activities that met the needs and interests of another resident. This resident, who had mild cognitive impairment and visual limitations, required activities compatible with their physical and mental capabilities, such as large print materials. However, the activity aide provided the resident with a regular print sudoku puzzle book and a coloring book, which did not accommodate the resident's visual needs. This oversight indicates a lack of attention to the resident's specific requirements as outlined in their comprehensive care plan.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The Unit Manager contacted the provider to obtain Resident #12's updated treatment records, including recent lab results, treatment schedules, and any noted concerns. Resident #12's care plan was reviewed and updated to reflect current care needs, including accurate documentation and proper communication with providers, followed by monthly audits of 3 resident's records for an additional three months. Audit results will be reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) meetings, with corrective actions taken as needed. Compliance monitoring will continue until sustained improvement is demonstrated, as determined by QAPI oversight. (e) The date of compliance is .
Failure to Report Allegations of Neglect and Protect Resident
Penalty
Summary
The facility failed to report allegations of neglect and protect a resident during an investigation. A resident, who had been at the facility for over two years, experienced an incident where a nurse attempted to administer a discontinued medication and another medication that the resident preferred to take every other night. The resident, who primarily spoke Spanish, tried to communicate with the English-speaking nurse about the medication error. During the interaction, a pill fell on the floor, and the nurse placed it back in the cup with the other medications. The resident refused to return the pills until she spoke with a supervisor, but the nurse left without calling one. The resident reported the incident to the MDS Coordinator the following morning, who then informed the management. The Director of Nursing (DON) and the nurse involved confronted the resident, allegedly yelling and calling her a liar. The resident felt disrespected and reported the incident to the Department of Children and Families (DCF), who visited the facility and took pictures of the pills. Despite the resident's request not to have the same nurse assigned to her again, the nurse was reassigned to her, causing the resident distress and fear of retaliation. The facility's reportable log did not show any neglect allegations reported by the resident. The Administrator acknowledged the DCF visits but did not consider the incidents as neglect, citing the time frame of care as a factor. The facility's policy on neglect and abuse was not followed, as the allegations were not reported to the State Agency, and the resident was not protected during the investigation.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: Upon identification of the deficiency, the facility immediately self-reported the allegation to the State Agency. The accused nurse was removed from the schedule pending an investigation. Resident #56 was assessed by social services to ensure emotional and physical well-being. Supportive interventions, including psych services and reassurance, were provided. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents have the potential to be affected. A review of grievances for the last 60 days was conducted by the Interdisciplinary Team, which included the Administrator, Social Services, DON, RVP, and Regional Nurse to determine if any other allegations of neglect had been unreported or inadequately investigated. Any identified concerns were immediately self-reported and addressed. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: The Coordinator and Director of Nursing were educated on by the RVP on reporting requirements utilizing FHCAs Decision Tree. Starting on all staff will receive mandatory training on identification, mandatory reporting, and investigation protocols. All staff will be in-service by. Any staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Administrator or designee will conduct audits of five grievances per week for two months, followed by ten grievances per month for a minimum of three additional months, to ensure appropriate reporting and implementation of protective actions. Results of the audits will be reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) meetings, with corrective actions implemented as needed. (e) The date of compliance is.
Failure to Promote Resident Dignity in Dining
Penalty
Summary
The facility failed to promote dignity in dining for a resident, identified as #51, who was part of a sample of 59 residents reviewed for dignity. The deficiency was observed when a Certified Nursing Assistant (CNA) referred to the resident as a "feeder," a term used to describe residents who require assistance with eating. This term was used during a conversation with a surveyor and was also noted in the resident's care plan, known as the Kardex. The CNA questioned whether this terminology was appropriate, indicating a lack of awareness about its impact on resident dignity. The Director of Nursing acknowledged that referring to residents as "feeders" is a dignity issue and confirmed that CNAs should not use such terms. Despite having passed the required competencies for her job, which included maintaining and enhancing a patient's self-worth, the CNA used language that did not align with the facility's policy on promoting and maintaining resident dignity. The facility's policy, revised recently, emphasizes the intent to protect and promote resident rights and to treat each resident with respect and dignity.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: CNA H was counseled regarding the inappropriate and provided immediate re-education on maintaining resident dignity and respectful communication. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents who require assistance during meals have the potential to be affected. Residents with a score of 12 and over were interviewed by the Social Services Staff and Administrator to determine if they have experienced or witnessed any undignified language or treatment. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all staff will receive mandatory training on resident rights, dignity, and person-centered communication, with a focus on respectful language. All staff will be in-service by Any staff not in serviced by this date will be in serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing (DON) or designee will conduct 5 meal service audits weekly for 1 month, then 10 monthly for at least two additional months, to ensure staff are promoting dignity. Findings from audits will be reviewed in the facility's Quality Assurance and Performance improvement meetings, and corrective actions will be taken as needed. Compliance monitoring will continue until sustained improvement is demonstrated, as determined by QAPI oversight. (e) Date of compliance
Failure to Notify POA of Medication Change
Penalty
Summary
The facility failed to notify the emergency contact and Power of Attorney (POA) of a change in medication for a resident who was unable to make healthcare decisions independently. The resident, who had a history of disorientation and poor judgment, was discharged from the hospital with specific medication orders. However, the facility's physician altered the medication regimen without informing the resident's son, who was the designated healthcare surrogate and POA. This change in medication affected the resident's alertness and ability to participate in daily activities, as reported by the family. The facility's policy required that when a resident was incapable of making decisions, their representative should be informed of any changes. Despite this, the Unit Manager of the Specialized Subacute Unit acknowledged that the resident's son was not notified of the medication change, and there was no documentation of such notification in the resident's clinical record. This oversight led to a deficiency in the resident's right to be informed and participate in their treatment decisions, as outlined in the federal regulations.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The responsible party for Resident #20 was notified of the dosage adjustment and current medication regime for. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents have the potential to be affected. A review of all recent medication changes over the past 14 days was conducted to ensure responsible parties were notified as required. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Licensed staff (RNs and LPNs) will receive mandatory training on the requirement/policy to notify residents and/or responsible parties of medication changes and the facility's Notification of Changes Policy, ensuring clear expectations for timely documentation. All Licensed staff will be in-service by. Any Licensed staff not in serviced by this date will be in-service prior to their next scheduled shift. We have no Agency staff currently. All newly hired Licensed staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing or designee will conduct audits of medication changes Monday thru Friday for 2 weeks, then 10 monthly for three months, to ensure responsible party notifications are completed and documented. Any instances of non-compliance will result in immediate re-education and corrective action. Audit results will be reviewed during the facility's monthly Quality Assurance and Performance Improvement meetings. (e) Date of Compliance
Failure to Evaluate Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a resident was evaluated for safe self-administration of medications. Resident #5, who had intact cognition as per the Minimum Data Set (MDS) quarterly assessment, was observed with a medication cup containing various pills on her bedside table without staff supervision. Registered Nurse (RN) D later entered the room and asked the resident to take her medications, which she did. However, there was no physician order or plan of care documented for the resident to self-administer medications. RN D admitted to leaving the medications with the resident and stepping out of the room, which was against the facility's policy. The Unit Manager (UM) and Director of Nursing (DON) confirmed that medications should not be left at the bedside and must be administered under supervision. The facility's policy requires an interdisciplinary team to determine if a resident can safely self-administer medications, but this process was not followed for resident #5.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected: The nurse ensured that Resident #5 took medications provided. The physician was notified of the incident, and no negative outcomes were identified. The nurse involved was re-educated on proper medication administration practices, including the requirement to observe the resident taking medications and ensure proper documentation. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents have the potential to be affected. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Licensed staff (RNs and LPNs) will receive mandatory training on medication administration policies, emphasizing the prohibition of leaving medications unattended. All Licensed staff will be in-service by. Any Licensed staff not in serviced by this date will be in-service prior to their next scheduled shift. We have no Agency staff currently. All newly hired Licensed staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The DON or designee will conduct weekly audits of medication administration with 2 nurses for at least 2 Residents 3 times a week for 2 weeks, then at least 8 Residents monthly for three months to ensure adherence to the policy. Any non-compliance identified will result in immediate re-education and corrective action. Audit findings will be reviewed during the facility's monthly Quality Assurance and Performance Improvement (QAPI) meetings. (e) Date of compliance:
Failure to Report Allegations of Neglect and Mistreatment
Penalty
Summary
The facility failed to report allegations of neglect and mistreatment involving a resident to the State Agency and did not protect the resident during the investigation. The resident, who had been in the facility for over two years, reported an incident where a nurse attempted to administer a discontinued medication and another medication that the resident preferred to take every other night. The resident, who primarily spoke Spanish, tried to communicate with the nurse, who only spoke English, about the medication error. During the interaction, a pill fell on the floor, and the nurse placed it back in the cup with other medications, which the resident refused to take. The resident requested to speak with a supervisor, but the nurse did not comply and left the room. The following morning, the resident reported the incident to the MDS Coordinator, who arranged for a Spanish-speaking staff member to assist with communication. The Director of Nursing (DON) and the night nurse confronted the resident, allegedly yelling and calling her a liar. The resident felt disrespected and reported the incident to the Department of Children and Families (DCF), who visited the facility and took pictures of the pills. The resident expressed fear of retaliation and reported previous issues with staff not providing timely personal care. Despite the resident's request not to have the same nurse assigned to her, the nurse was reassigned to her care, causing further distress. The facility's reportable log did not include the resident's allegations, and the Administrator (NHA) was unaware of the DCF's visit concerning the resident's complaints. The NHA and DON did not initially report the incident as neglect, and the facility's policy on reporting and investigating allegations was not followed. The DCF Investigator confirmed discussing the allegations with the facility, but the NHA claimed not to have been informed of the specific reasons for the DCF's visit. The facility's failure to report and investigate the allegations properly resulted in a deficiency in meeting regulatory requirements.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: Upon identification of the deficiency, the facility immediately self-reported the allegation to the State Agency. The accused nurse was removed from the schedule pending an investigation. Resident #56 was assessed by social services to ensure emotional and physical well-being. Supportive interventions, including psych services and reassurance, were provided. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents have the potential to be affected. A review of grievances for the last 60 days was conducted by the Interdisciplinary Team, which included the Administrator, Social Services, DON, RVP, and Regional Nurse to determine if any other allegations of neglect had been unreported or inadequately investigated. Any identified concerns were immediately self-reported and addressed. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: The Coordinator and Director of Nursing were educated on reporting requirements utilizing FHCAs Decision Tree. Starting on all staff will receive mandatory training on identification, mandatory reporting, and investigation protocols. All staff will be in-service by Any staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Administrator or designee will conduct audits of five grievances per week for two months, followed by ten grievances per month for a minimum of three additional months, to ensure appropriate reporting and implementation of protective actions. Results of the audits will be reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) meetings, with corrective actions implemented as needed. (e) The date of compliance is . F 609
Inaccurate MDS Assessment for Major Injury
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident, specifically regarding the documentation of a major injury. The resident, who had been readmitted from an acute care hospital, reported having broken his right bone after a fall while coming out of the bathroom. Despite this incident, the MDS Discharge Assessment and the 5-day assessment did not reflect the resident's status of having a major injury. This discrepancy was acknowledged by the MDS Transitional Nurse responsible for completing the assessments. The MDS Transitional Nurse admitted that the assessments did not indicate the major injury status of the resident, despite having reviewed hospital documentation before completing the MDS assessment and care plan. The Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual provides specific instructions for coding major injuries, which were not followed in this case. The facility's policy requires comprehensive and accurate assessments of each resident's functional capacity, which was not adhered to in this instance.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The MDS for Resident #109 has been reviewed and corrected to accurately reflect the with major injury. The Care Plan for Resident #109 has been reviewed and updated to include interventions related to prevention and management. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents who have had a have the potential to be affected. A facility-wide audit of all current residents who experienced in the past 90 days has been conducted to ensure the MDS accurately reflects their history and any major injuries. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: On all staff responsible for MDS completion, including the MDS Coordinator and MDS Assistant, have been re-educated by Regional Nurse on the proper coding of with major injuries to include training on accurate MDS documentation, specifically regarding Section J1900 (with Injury). Also, education was provided to ensure that all hospital diagnoses, including, are promptly reviewed and incorporated into MDS assessments and care plans. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing (DON) or designee will conduct weekly audits of 3 completed MDS for accuracy in section J1900, with a focus on with major injuries, for 2 months, then monthly for at least three additional months. Audit results will be reviewed in the facility's Quality Assurance and Performance Improvement meetings, and corrective actions will be implemented as needed. Compliance monitoring will continue until sustained improvement is demonstrated, as determined by QAPI oversight. (e) Date of compliance
Deficiencies in Care Plan Implementation and Communication
Penalty
Summary
The facility failed to implement an individualized comprehensive care plan for a resident reviewed for safety precautions. The resident, who had difficulty being understood, was observed with unpadded bed rails despite the care plan specifying padding for safety. A CNA confirmed the absence of padding and was unaware of why the pads were not in place. The Restorative Unit Manager stated that padding was only applied at night due to the resident's agitation during that time. The Director of Nursing expected staff to review and implement care plans, which was not adhered to in this instance. Another deficiency was noted for a resident reviewed for communication needs. This resident, whose primary language was Spanish, expressed a desire for an interpreter when communicating with healthcare staff. Despite this, the care plan did not address her communication needs or preference for Spanish-speaking staff. The resident experienced a communication issue with a nurse regarding medication, which led to distress and a lack of resolution as no supervisor visited her that night. The MDS Coordinator acknowledged the absence of a communication care plan and confirmed that the resident's preference for an interpreter was documented in the MDS assessment. The facility's policy on comprehensive care plans emphasizes the development of person-centered plans that incorporate residents' personal and cultural preferences. However, the facility failed to adhere to this policy in the cases of the two residents. The care plans did not adequately address the specific needs and preferences of the residents, leading to deficiencies in their care and communication, as observed during the survey.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: For Resident #92, the pads were placed as per the Resident's care plan. Resident #92 was reassessed to ensure all precautions were properly implemented. CNA Q was re-educated on the importance of following care plan interventions, especially for residents with. For Resident #56, the care plan was updated to reflect the resident's primary language of Spanish with the intervention of utilizing an interpreter as indicated. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents with a diagnosis of and Residents who do not speak English proficiently have the potential to be affected. A facility-wide audit of all residents with was conducted to ensure appropriate interventions were care planned and in place. MDS Coordinator conducted an audit of all residents with limited English proficiency to ensure their communication needs were appropriately care planned. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Nurse leadership team, including Director of Nursing, Assistant Director of Nursing, Unit Managers, and MDS Nurses received in-service training on by Regional Nurse on the requirement for comprehensive Resident Centered care plans with focus on Residents with and/or limited English proficiency. Starting on all Direct Care staff (RNs, LPNs, and C.N.A.S) will receive mandatory training on the importance of following individualized care plan interventions, ensuring safety interventions are in place for precautions per plan of care, and on communicating with Residents with limited English proficiency per plan of care to include use of Propio 1 Interpreter Line. All Direct Care staff will be in-service by. Any Direct Care staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Direct Care staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing or designee will conduct weekly audits of 5 Residents with or Limited English Proficiency for four weeks, then 10 monthly for at least three months, to ensure care plans are accurately implemented and followed. Any discrepancies found will result in immediate correction and staff re-education. Audit results will be reviewed in the facility's monthly Quality Assurance and Performance Improvement (QAPI) meetings. (e) The compliance date is.
Failure to Revise and Implement Care Plans Leads to Resident Falls
Penalty
Summary
The facility failed to revise and implement appropriate interventions for two residents, leading to deficiencies in their care plans. Resident #3, who had severe cognitive impairment and hearing loss, experienced multiple falls, including one that resulted in a hematoma on her forehead. Despite her need for frequent supervision and assistance, the care plan did not include interventions for 15-minute checks or adequate supervision. The resident's daughter expressed concerns about the lack of supervision and the resident's tendency to attempt tasks independently, which contributed to her falls. Resident #51, also with severe cognitive impairment, experienced falls from her wheelchair in the TV room. The care plan included the use of a dycem to prevent sliding, but it was not consistently used or documented in the resident's Kardex. Staff members were unaware of the dycem's absence, and the resident's care plan did not reflect the necessary interventions for increased supervision, especially during the evening when the resident's behaviors worsened. The facility's policies on accidents and supervision, as well as comprehensive care plans, were not effectively implemented. The interdisciplinary team failed to update care plans with appropriate interventions after incidents, and communication among staff regarding care plan changes was inadequate. This lack of coordination and oversight contributed to the residents' repeated falls and the facility's failure to meet regulatory requirements for comprehensive care planning.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: New risk evaluations were completed for Resident #51 to reflect accurate information, and their care plans and Kardex's were updated to reflect accurate risk assessments, with appropriate and individualized prevention interventions implemented. Resident #3 is no longer residing at the facility. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents who have had a have the potential to be affected. The MDS Coordinator and Unit Managers conducted a facility-wide audit of risk assessments and care plans for residents with a score of 12 or less to identify any discrepancies. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Direct Care staff (RNS, LPNs, and C.N.A.S) staff will receive mandatory training regarding review and use of Care Plan/Kardex prior to providing care to Residents. This education will also be completed upon hire and at least annually. All Direct Care staff will be in-service by . Any Direct Care staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Direct Care staff will be in-service by the ADON during their orientation. Starting on all Licensed nurses (RNs and LPNs) and MDS staff on the proper completion of risk assessments, Individualized care planning, and the importance of ensuring interventions are documented in the Kardex. All Licensed nurses (RNs and LPNs) and MDS staff will be in-service by . Any Licensed nurses (RNs and LPNs) and MDS staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Licensed nurses (RNs and LPNs) and MDS staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing or Designee will review a sample of five residents' risk evaluations, care plans and Kardex's weekly for four weeks, then monthly for three months to ensure continued compliance. Any discrepancies identified will be corrected immediately, and trends will be addressed through additional staff training or process adjustments. Findings will be reported in the monthly QA/QAPI meeting for further review and action as needed for a minimum of 3 months. (e) Date of compliance
Failure to Provide Appropriate Activities for Visually Impaired Resident
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the needs and interests of a resident, identified as Resident #58, who was part of a sample of 59 residents. The resident had been diagnosed with conditions including visual impairment and required large print materials for reading. Despite this, the facility provided the resident with a regular print sudoku puzzle book and a coloring book, which the resident could not use due to her visual limitations. This led to the resident expressing frustration and stating that she could not see the contents of the books. Observations revealed that the resident was often left without appropriate activities. On multiple occasions, the resident was seen either standing at her door or sitting on her bed without any suitable activities being provided. The Activity Director acknowledged that the materials given to the resident did not meet her needs, as they were not compatible with her physical and mental capabilities. The facility's assessment indicated that care should be based on evidence-based, data-driven methods considering the resident's conditions and needs, which was not adhered to in this case.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: Resident #58 was assessed for activity preferences. Preferences were added to the care plan. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents with visual have the potential to be affected. 100% audit of all MDS assessments to identify residents with visually. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: The Administrator provided education to Activity Director and Activity Staff starting on regarding resident activity preferences and ensuring activities are compatible with the Residents physical and mental capabilities. Activity Director and Activity Staff will be in-service by The Activity Director and Activity Staff not in serviced by this date will be in serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Activity Director and Activity Staff will be in-service by the ADON during their orientation. The Activity Director will complete Activity Preference assessment on all visually residents. (d) How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Administrator or designee will interview at least 5 residents weekly for 4 weeks for activity preferences offered as desired, then interview 10 residents monthly for the 3 months. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee. (e) The compliance date is.
Lack of Communication with External Treatment Center
Penalty
Summary
The facility failed to maintain ongoing communication and collaboration regarding the care and services for a resident who required specific treatments at an external center. The resident's medical record showed no documentation of communication between the facility's nursing staff and the external center from a specified period. The Unit Manager expected the facility's Communication Record to be completed and sent with the resident to the center, and for the nursing staff to review and include the returned form in the resident's medical record. However, there were no Communication Records or any other documentation of communication with the center in the resident's medical record. Interviews with staff from both the facility and the external center revealed that the facility used to send a binder for communication, but it had not been used for six months or more. The Clinical Manager and Clinical Nurse at the center confirmed that they had not received regular communication from the facility after each session, and sometimes faced difficulties in reaching the resident's nurse at the facility. The Assistant Director of Nursing acknowledged the importance of communication for coordinating care and verified the absence of documentation in the resident's electronic medical record, indicating a lapse in the facility's communication practices.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The Unit Manager contacted the provider to obtain Resident #12's updated treatment records, including recent lab results, treatment schedules, and any noted concerns. Resident #12's care plan was reviewed and updated to reflect current care needs, including communication protocols between the facility and the provider. (b) Identification of other residents having the potential to be affected was accomplished by: All residents receiving have the potential to be affected. A facility-wide audit was conducted to identify all residents receiving and assess the adequacy of communication and documentation related to their care. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Licensed staff (RNs and LPNs), including unit managers, received education on care coordination, proper documentation, and the importance of interdisciplinary collaboration. All Licensed staff (RNs and LPNs), including unit managers will be in-service by Any Licensed staff (RNs and LPNs), including unit managers not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Licensed staff (RNs and LPNs), including unit managers will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing or designee will conduct weekly audits of all residents' records for one month, ensuring accurate documentation and proper communication with providers, followed by monthly audits of 3 residents' records for an additional three months. Audit results will be reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) meetings, with corrective actions taken as needed. Compliance monitoring will continue until sustained improvement is demonstrated, as determined by QAPI oversight. (e) The date of compliance is
Failure to Document Medication Administration
Penalty
Summary
The facility failed to accurately document the administration of medications in the Medication Administration Record (MAR) for a resident. The resident, who was readmitted with diagnoses including type 2 diabetes, complained of severe pain rated 10 out of 10. Although the resident reported the pain to a nurse and was subsequently given medication by a Registered Nurse (RN), the administration of the medication was not documented in the MAR. Additionally, there was no progress note entered by the RN regarding the administration of the medication or the resident's pain on that day. The facility's policies require that all services provided, including medication administration, be documented accurately in the medical record to facilitate communication among the interdisciplinary team. The General & Restorative Unit Manager and the Director of Nursing both emphasized the importance of accurate documentation, which was not adhered to in this instance. The failure to document the medication administration and the resident's condition was a deviation from the facility's established procedures and expectations.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: Resident # 18 assessed for, No. Notified physician and advised to discontinue order. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents receiving medication have the potential to be affected. An audit was conducted for all current Residents receiving meds to ensure the assessment was completed and the medication administration was documented. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Nursing staff (RNs, LPNs) will receive mandatory Education for all nurses on accurately documenting of PRN medications on the MAR. All Nursing staff will be in-service by. Any Nursing staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Nursing staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not reoccur: DON, Unit managers or designee will observe 2 nurses' medication administration of 2 residents 3 times a week for 2 weeks, then 2 nurses' medication administration for 2 residents once a week for 3 months to ensure compliance. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee. (e) The date of compliance is.
Failure in Communication with Hospice Services
Penalty
Summary
The facility failed to maintain effective communication between nursing staff and hospice services, leading to inadequate treatment, monitoring, and continuity of care for two residents receiving hospice care. Resident #3, who had severe cognitive impairment and was receiving hospice care, experienced multiple falls and changes in condition. Despite the facility's policy requiring immediate notification to hospice staff, the hospice was not informed of these incidents, including a significant fall that resulted in a hospital visit. Interviews with facility staff and hospice personnel revealed a lack of documentation and communication regarding these changes in condition. Resident #469, who had severe cognitive impairment and was under hospice care, experienced a fall and subsequent pain, which was not communicated to the hospice in a timely manner. The resident's granddaughter was informed of the incident by the hospice nurse, not the facility, and requested a hospital transfer. The hospice nurse and social worker confirmed they were not notified of the resident's fall and subsequent condition changes, despite the facility's policy and agreement with the hospice provider requiring such communication. The facility's Director of Nursing and other staff acknowledged the expectation for nurses to communicate any changes in condition to hospice staff and document these communications. However, the lack of adherence to these protocols resulted in a failure to provide coordinated care for residents receiving hospice services, as evidenced by the incidents involving residents #3 and #469.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The Hospice provider was made aware on of the regarding resident #3 during an in-person visit. The hospice provider was made aware on of the for resident #469 via phone call with case manager. In person communication re: between hospice provider and facility occurred on. Residents #3 and #469 are no longer residing at the facility. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents receiving Hospice services have the potential to be affected. A facility-wide audit was conducted to identify all residents receiving hospice services and assess the adequacy of communication of with hospice providers occurred timely. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Nursing staff (RNs and LPNs), including unit managers, received education on hospice care communication, proper documentation, and the importance of interdisciplinary collaboration. Nursing staff (RNs and LPNs), including unit managers, will be in-service by Any Nursing staff (RNs and LPNs), including unit managers not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Nursing staff (RNs and LPNs), including unit managers, will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing or designee will conduct weekly audits of all hospice residents' records for 4 weeks, ensuring accurate documentation and proper communication with hospice providers, followed by monthly audits of 3 hospice residents' records for an additional three months. Audit results will be reviewed in the facility's Quality Assurance and Performance improvement (QAPI) meetings, with corrective actions taken as needed. Compliance monitoring will continue until sustained improvement is demonstrated, as determined by QAPI oversight. (e) The date of compliance is
Failure to Sanitize Monitoring Device Between Residents
Penalty
Summary
During a medication administration task, a Registered Nurse (RN) failed to clean a portable monitoring device between its use on two residents. The RN used the device to take the vital signs of one resident and then proceeded to use it on another resident without sanitizing it in between. The RN admitted to being stressed and forgetting to clean the device, which is a required procedure to prevent cross-contamination between residents. The facility's Infection Preventionist (IP) confirmed that the staff had been trained to use purple top wipes to sanitize equipment, following the manufacturer's guidelines for drying and contact times. However, the RN involved had not signed the recent in-service training on this procedure. The Director of Nursing (DON) reiterated the expectation that all equipment should be cleaned between uses to prevent cross-contamination, as outlined in the facility's policy and CDC recommendations.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The monitor was Residents #98 and #1 received a skin check and there was no evidence of Inservice for RN D on proper monitor by IP nurse. (b) Identification of other residents having the potential to be affected was accomplished by: The facility has determined that all residents have the potential to be affected. All monitors were. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all licensed and certified nursing staff (RNs, LPNs, and C.N.A.s) were educated in Prevention and Control Policy, proper of the monitor, and their roles in preventing the spread of communicable and licensed and certified nursing staff (RNs, LPNs, and C.N.A.s) will be in-service by. Any licensed and certified nursing staff (RNs, LPNs, and C.N.A.s) not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired licensed and certified nursing staff (RNs, LPNs, and C.N.A.s) will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not: The IP nurse or designee will observe 2 staff 3 times a week for proper monitor for of 2 weeks then 2 staff twice weekly for 2 weeks then 2 staff monthly for up to 3 months. Any deficient practice found during the audits will be corrected immediately by the IP nurse or designee and/or corrective action done as appropriate. This plan of correction will be monitored at the QAPI meeting until such time consistent substantial compliance has been met. The IP Nurse will report the audit findings in the QAPI meeting. (e) The date of compliance is.
Failure in Antibiotic Stewardship Program Monitoring
Penalty
Summary
The facility failed to develop a comprehensive system to monitor antibiotic use, as required by the stewardship program under CFR 483.80(a)(3). The review of records revealed that several residents were prescribed antibiotics without proper monitoring or follow-up testing. Specifically, resident #99 was prescribed an antibiotic without a subsequent culture and sensitivity test to confirm the appropriateness of the treatment. Additionally, residents #53, #87, and #20 were also receiving antibiotics, but their cases were not included in the facility's Control Report, which is supposed to track all antibiotic use. The Assistant Director of Nursing (ADON) and Infection Preventionist (IP) admitted to not analyzing trends in antibiotic prescribing or ensuring that all residents on antibiotics were included in the monthly Control Report. The facility's surveillance policy required tracking of all residents and their antibiotic use, but this was not adhered to. The ADON/IP also confirmed that the oversight led to residents not being part of the Control Report, which is reviewed during the facility's Quality Assurance meetings. This lack of a comprehensive monitoring system indicates a failure to adhere to the facility's stewardship commitment statement, which was signed by key personnel, including the Administrator and Medical Director.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The Preventionist conducted an audit of all residents currently receiving to ensure appropriate indications, duration, and monitoring. The facility notified prescribing providers to ensure compliance with stewardship guidelines and discontinued or adjusted any orders that did not meet clinical necessity. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents receiving have the potential to be affected. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Nursing staff (RNs and LPNs) will receive education by the Preventionist on stewardship, including appropriate specimen collection, early signs of, and the risks of overuse. All Nursing staff (RNs and LPNs) will be in-service by Any Nursing staff (RNs and LPNs) not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Nursing staff (RNs and LPNs) will be in-service by the ADON during their orientation. The Preventionist was educated by the Regional Nurse on regarding Stewardship and Control Policy. (c) How the corrective action(s) will be monitored to ensure the practice will not recur: The Preventionist will conduct audits of all new orders for compliance with stewardship protocols 5 days per week for 2 weeks then at least 5 weekly for two months, and monthly thereafter. Findings will be reported during the monthly QAPI meetings, and corrective actions will be implemented as needed. Compliance with the Stewardship Program will be reviewed during the facility's annual control risk assessment.
Failure to Conduct Annual Air Flow Testing for Duct Detectors
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with the National Fire Protection Association (NFPA) 101 standards. During a record review with the Maintenance Director, it was found that there was no evidence of the annual air flow testing for the duct detectors being conducted. This deficiency was identified during an interview and record review on February 24, 2025, at 8:45 AM. The Maintenance Director acknowledged and concurred with the findings, indicating a lapse in the required testing and maintenance procedures. The report highlights that the facility did not comply with the NFPA 101 and NFPA 72 codes, which require regular testing and maintenance of fire alarm systems. The absence of documentation for the duct detectors' annual air flow testing suggests a failure to adhere to these safety standards, which are critical for ensuring the proper functioning of the fire alarm system. This oversight was confirmed through both the record review and the interview with the Maintenance Director.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The Duct Detectors annual air flow testing was scheduled and completed on 3/25/25. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents have the potential to be affected. The Maintenance Director reviewed all the other required Fire Alarm System testing and found no other testing deficiencies. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: The Administrator provided re-education to the Maintenance Director and Maintenance staff on the Fire Alarm System on 3/14/25 to include: Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72). (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or Designee will review All Fire Alarm System testing weekly for 4 weeks and then monthly for 2 months to ensure compliance. Any discrepancies identified will be corrected immediately, and trends will be addressed through additional staff training or process adjustments. Findings will be reported in the monthly QA/QAPI meeting for further review and action as needed for a minimum of 3 months. (e) The compliance date is 3/28/25. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The Duct Detectors annual air flow testing was scheduled and completed on 3/25/25. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents have the potential to be affected. The Maintenance Director reviewed all the other required Fire Alarm System testing and found no other testing deficiencies. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: The Administrator provided re-education to the Maintenance Director and Maintenance staff on the Fire Alarm System on 3/14/25 to include: Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72). (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or Designee will review All Fire Alarm System testing weekly for 4 weeks and then monthly for 2 months to ensure compliance. Any discrepancies identified will be corrected immediately, and trends will be addressed through additional staff training or process adjustments. Findings will be reported in the monthly QA/QAPI meeting for further review and action as needed for a minimum of 3 months. (e) The compliance date is 3/28/25.
Failure to Follow Physician Orders for Medication and Monitoring
Penalty
Summary
The facility failed to adhere to physician orders for a resident who was admitted for respite care with diagnoses including brain cancer, cachexia, and quadriplegia. The resident had a PEG tube for feeding assistance. A physician's order dated May 11, 2024, required the administration of Midodrine HCl 10 mg twice daily for hypotension. However, the Medication Administration Report (MAR) for May 2024 showed that on May 14, 2024, at 9:00 PM, the administration record for this medication was left blank, indicating a failure to document or possibly administer the medication. Additionally, the facility did not comply with a physician's order dated May 10, 2024, to monitor the resident's vital signs every 12 hours, including blood pressure, pulse, respirations, and temperature. The MAR for May 2024 also showed that on May 14, 2024, at 9:00 PM, there was no documentation of vital signs being obtained. Furthermore, another order required checking the PEG tube residual every shift and notifying the MD, but the MAR indicated that this was not done on the same date and time. The Director of Nursing confirmed these omissions but did not provide an explanation for the failure to follow or document the orders.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent worsening of existing pressure ulcers for three residents. Resident #3, who was admitted with a stage 3 pressure ulcer, did not receive the prescribed wound care treatments as there were no orders documented in the Treatment Administration Record (TAR) or clinical record after 4/21/24. Despite multiple evaluations by the Wound Specialist physician recommending specific treatments, these were not recorded or administered, and the resident's wound was observed without the appropriate dressing. Resident #17, admitted with a stage 4 pressure ulcer, also did not receive the correct treatment as per the Wound Specialist physician's recommendations. The clinical record lacked orders for Zinc Sulfate and the updated Vitamin C dosage, and the resident was incorrectly administered Venelex ointment instead of the recommended treatments. The facility staff documented the administration of Venelex in the electronic Medication Administration Record (eMAR) instead of the TAR, leading to a failure in following the correct treatment plan. Resident #9, with a stage 4 pressure ulcer, received incorrect treatment from 4/18/24 to 6/12/24. The resident was supposed to receive Calcium Alginate with silver, but instead received Calcium Alginate without silver, which lacks the antimicrobial properties necessary for effective wound care. The facility's failure to update and follow the wound care orders as prescribed by the Wound Specialist physician contributed to the deficiencies observed in the care of these residents.
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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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