Life Care Center Of Port Saint Lucie
Inspection history, citations, penalties and survey trends for this long-term care facility in Port Saint Lucie, Florida.
- Location
- 3720 Se Jennings Rd, Port Saint Lucie, Florida 34952
- CMS Provider Number
- 106012
- Inspections on file
- 27
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Life Care Center Of Port Saint Lucie during CMS and state inspections, most recent first.
Uncomfortable Room Temperatures: Multiple residents complained that their rooms were freezing or too cold, and survey observations confirmed room temperatures in the high 60s to about 70 degrees F, with some thermostats set much higher than the actual readings. Residents with intact cognition described needing extra blankets, wearing heavy sweaters, or being unable to rest comfortably, while hallways and a therapy area were also measured below 71 degrees F.
Failure to administer PRN antihypertensive medication as ordered. A resident with HTN and moderate cognitive impairment had a care plan directing staff to give antihypertensive medication as ordered. The physician ordered BP checks every 8 hours and clonidine HCL 0.1 mg PO q8h PRN for systolic BP over 160, but the MAR showed multiple elevated systolic BP readings above 160 with clonidine documented only twice.
Respiratory care was not provided as ordered for multiple residents. One resident with acute/chronic respiratory failure was repeatedly observed with the NC not properly positioned, and at one point the O2 tank on the wheelchair was closed while the resident’s O2 sat was 79% until wall O2 was applied. Another resident with COPD was found with an empty O2 tank despite an order for continuous O2, a third resident with COPD did not receive a scheduled breathing treatment even though the MAR had already been signed, and a fourth resident’s O2 tubing was found on the floor and later remained in use.
Bed rail use was not properly assessed, ordered, consented to, or reassessed for multiple residents. Several residents were observed with bed rails up, but records showed missing or incomplete bed rail evaluations, no physician orders for some residents, no signed consent for some residents, and assessments that were not completed quarterly. Staff stated bed rails were automatically put up on admission and that consents and physician orders were not obtained at that time.
An LPN administered IV cefepime to a resident using a different concentration than the physician ordered, and multiple nurses had given the same IV medication without clarifying the order. In a separate observation, an LPN brought medications for two residents into a shared room, gave each resident a medication cup without explaining the medications, and did not provide privacy during administration.
Medication administration and narcotic reconciliation were not properly completed for several residents. Controlled substance records showed missing administration times or dates for Tramadol and Oxycodone, one Oxycodone count did not match the pill packet, and an LPN admitted giving a dose without signing it out. In one case, Oxycodone was documented as given even though the MAR showed no administration and the order had already been discontinued.
A resident receiving Seroquel for psychosis had an AIMS documented with a score of 0.0, but the facility did not complete the quarterly monitoring when it was due. The resident had diagnoses including dementia, psychotic disturbance, MDD, and anxiety, and the ADON acknowledged the AIMS should have been done quarterly.
Medication administration errors were identified during med pass observations, interviews, and record review, resulting in a 9.38% error rate. An LPN administered an IV antibiotic in the wrong concentration for one resident, and for two other residents, an LPN documented medications as given even though they were not observed during the med pass, including a cholesterol medication and a Symbicort inhaler.
Medications were left unattended at the bedside for two residents, including one resident with dementia and visual impairment who had scheduled Quetiapine and Namenda left in a medicine cup, and another resident whose nightstand held two bottles of medication without orders or a self-medication assessment. Surveyors also found two opened, unlabeled insulin vials in a med room refrigerator and several expired medications in a med cart.
The facility did not consistently perform or document weekly skin assessments for three residents at risk for pressure ulcers, despite facility policy, care plan interventions, and physician orders requiring these checks. Nursing staff confirmed that the electronic system was intended to prompt and record these assessments, but multiple weeks were missed for each resident, including periods where staff signed off on records without completing the required documentation.
A resident experienced a significant, unaddressed weight loss over several weeks due to the facility's failure to follow its weight monitoring policy, missed required weigh-ins, and lack of timely communication and intervention by staff. The resident's weight loss was not promptly reported to the physician or addressed in care planning meetings, and interventions were delayed despite clear evidence of nutritional decline.
A resident with a history of right femur fracture and fragile skin sustained bruises during a stand pivot transfer when a CNA failed to stop as requested. The facility did not document an assessment of the injuries, failed to complete an incident report, and did not conduct or document a thorough internal investigation or federal reporting, despite the incident being reported to the state agency. Staff interviews confirmed the lack of documentation and assessment, and the state agency substantiated the allegations.
The facility did not report allegations of abuse to the State Agency within the required timeframe for four residents involved in three separate incidents. In each case, the administrator reported the incidents to the Abuse Registry but delayed notification to the State Agency, sometimes by several hours or days. The administrator stated he was unaware of the 2-hour reporting requirement to the State Agency.
A resident with moderate cognitive impairment sustained a burn from hot tea due to inadequate temperature monitoring and management by the facility. The Dietary Aide and Cook failed to document temperature checks, and the Food Temperature Log showed multiple instances of hot beverages being served above the acceptable range. Additionally, the facility did not consistently follow physician-prescribed wound care orders, as indicated by missed treatments and incomplete documentation.
A resident with lumbar radiculopathy expressed dissatisfaction with her roommate and requested a room change, but the facility failed to document or address her grievance. Despite being alert and oriented, the resident's complaint was not logged or resolved, leading her to leave the facility AMA. Interviews with staff confirmed the lack of documentation and follow-up on the resident's request.
The facility failed to provide dignified care for several residents, with reports of staff having poor attitudes, delayed responses to call lights, and neglecting personal care needs. Residents reported feeling disrespected and ignored, with incidents of inappropriate comments, rushed care, and neglect of hygiene and comfort. These deficiencies highlight a pattern of inadequate care and lack of respect for residents' dignity.
The facility failed to maintain a safe, clean, and homelike environment in Units 100, 200, and 400. Observations revealed rusted and dusty ceiling vents, peeling paint, and damaged walls in several rooms. Additional issues included broken fixtures, dirty floors, and peeling paint on handrails, potentially causing safety hazards. The Director of Maintenance noted that wall damage was due to residents hitting them with wheelchairs or furniture.
The facility failed to provide adequate staffing, resulting in delayed and undignified care for residents. Multiple residents reported long wait times for assistance, leading to incidents of incontinence and rushed care. The Director of Nursing acknowledged staffing challenges, particularly on weekends, despite claiming there were enough CNAs. This deficiency affected the residents' well-being, as they were unable to receive timely and respectful care.
A facility failed to honor a resident's request to use an insulin sensor for glucose monitoring, opting instead for the more painful finger stick method. The resident, who was cognitively intact and had diabetes, expressed her preference for the sensor, which was not replaced or used by the facility. The necessary equipment remained at the associated Independent Living facility, and efforts were made to retrieve it.
A resident with hemiparesis, requiring substantial assistance with personal hygiene, experienced inadequate nail care despite multiple requests over two weeks. The resident's fingernails were long and unclean, with staff failing to address the issue during scheduled care opportunities. The responsible CNA was on vacation, leading to a lack of continuity in care.
The facility failed to follow physician-ordered parameters for medication administration for three residents, leading to deficiencies in care. A resident received midodrine despite high blood pressure readings, another experienced delays in antibiotic administration and PICC line dressing changes, and a third reported delays in receiving medications. Staff interviews revealed challenges in adhering to medication schedules due to workload.
A resident with moderate cognitive impairment and significant weight loss was not provided with the recommended nutritional supplements. Despite a dietician's note suggesting the addition of fortified foods and Med Pass, the physician's orders did not include these supplements, and the Registered Dietician confirmed the oversight.
A resident requiring tube feeding did not receive the prescribed amount of nutrition and fluids due to improper monitoring and administration. The resident was supposed to receive Glucerna 1.5, but observations showed an empty Jevity container instead. An LPN admitted to not clearing the pump volume and noted discrepancies in the canister's content, which were not questioned. The Unit Care Coordinator was unaware of the issue, and the Registered Dietician confirmed the resident's nutritional needs were unmet.
A resident with chronic pain did not receive timely pain management due to delays and missed doses of prescribed medications, including Gabapentin and topical patches. Staff interviews revealed challenges in adhering to medication schedules due to workload and logistical issues, resulting in the resident experiencing high pain levels.
A resident was found with open medications at their bedside due to suspicion about a medication, while another resident received expired Ferrex 150 mg from a medication cart containing expired medications.
The facility failed to provide an adequate protein portion during lunch, serving only 2.4 ounces of kielbasa instead of the required 4 ounces. This affected 70 residents on a regular diet, as the cook and CDM acknowledged the deficiency.
Uncomfortable Room Temperatures
Penalty
Summary
The facility failed to ensure comfortable room temperatures for 7 of 7 sampled residents who voiced complaints, with multiple resident rooms and common areas measured below 71 degrees F during a period of cold weather. Survey observations and interviews documented room temperatures in the high 60s to about 70 degrees F in the rooms of Residents #129, #128, #131, #76, #81, #105, and #83, along with hallway and therapy area temperatures also below 71 degrees F. Weather history reviewed during the survey showed multiple days of low outdoor temperatures during the survey week and prior 30 days. Resident #129, who had a BIMS score of 15, stated he was freezing and said he had told a CNA. He was observed in bed covered up to his neck, and his room temperature was measured at 68.0 degrees F, with the wall thermostat set to 78 degrees and the room reading 67 degrees. On a later observation, he again stated he was freezing and compared the conditions to being in New York; the room temperature was 70.3 degrees F, while the thermostat was set to 78 degrees and the room reading was 68 degrees. Resident #128, described as alert and oriented, had a room temperature of 69.4 degrees F with the wall thermostat set to 85 degrees and a room reading of 68 degrees, and stated it had been cold in the building. Resident #131 stated she was warm only because she was wearing a heavy sweater; her room measured 70.7 degrees F, had no thermostat, and cold air was felt coming from the ceiling vent near the door. Resident #76 stated it was too cold in her room and that she had needed extra blankets; her room measured 69.6 degrees F. Resident #81, who had a BIMS score of 15, stated it had been cold in the room the night before and later said it was still freezing; his room measured 70.3 degrees F, and later 67.1 degrees F. Resident #83 was observed shivering in a recliner under a blanket and stated it was really cold in her room; her thermostat read 68 degrees F and later she said it was still cold. Resident #105, who also had a BIMS score of 15, stated it was very cold the prior night, that maintenance had checked her room temperature at 67 or 68 degrees F, and that she had to sleep with three blankets; her room later measured 68 degrees F and she again stated it was still cold.
Failure to Administer PRN Antihypertensive Medication as Ordered
Penalty
Summary
The facility failed to follow physician orders for Resident #4 by not administering ordered blood pressure medication as prescribed. Resident #4 was admitted with a history of essential hypertension and cognitive communication deficit, and the comprehensive assessment documented a BIMS score of 10, indicating moderate cognitive impairment. The care plan identified hypertension as a focus and directed staff to give antihypertensive medication as ordered. A physician order dated 01/14/26 directed staff to check blood pressure every 8 hours and give clonidine HCL 0.1 mg by mouth every 8 hours as needed for systolic blood pressure over 160. Review of the January 2026 MAR showed multiple blood pressure readings above 160 systolic, including 161/90, 168/88, 169/84, 186/93, 161/75, 175/84, and 178/98, but clonidine was documented as administered only twice, on 1/22/26 at 9:48 PM and 1/26/26 at 11:07 PM.
Respiratory Care Not Provided as Ordered
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for multiple residents. One resident with acute and chronic respiratory failure and cognitive communication deficit was observed on several occasions with oxygen nasal cannula not properly in place, including only in one nostril and, at one point, wrapped around the face but not in the nostrils. During one observation, the oxygen tank on the back of the wheelchair was closed, and the resident’s oxygen saturation was initially 79% and then 82% until the tank was opened and the cannula was connected to wall oxygen, after which the saturation increased to 92%. The resident’s care plan directed staff to administer oxygen as ordered and observe for signs and symptoms of respiratory distress. Another resident with COPD and chronic respiratory failure was observed sitting in a wheelchair with an oxygen cannula attached to an empty tank. The resident stated it felt like the tank was empty. The physician order required continuous oxygen at 2 liters per minute via nasal cannula. A third resident with COPD stated she usually received breathing treatments twice a day, but the physician order required ipratropium-albuterol inhalation solution four times daily. On the day of observation, the resident reported she had not received the scheduled midday treatment, and the LPN later acknowledged the treatment had not been given even though the MAR had already been signed as administered. A fourth resident had an order for oxygen at 2 liters per minute as needed for shortness of breath and had used oxygen on prior days. During observation, the resident’s oxygen tubing dated 01/22/26 was found lying on the floor while still connected to the oxygen running at 2 liters per minute. The same tubing was later observed hanging over the oxygen regulator and then still in use days later. When asked what to do if oxygen tubing was found on the floor, an LPN stated she would throw it away and later said she would change it.
Bed Rail Assessments, Orders, and Consent Not Properly Completed
Penalty
Summary
The facility failed to ensure a proper assessment, physician order, informed consent, and quarterly reassessment for bed rail use for 5 of 6 sampled residents reviewed. The facility policy stated that alternatives must be attempted before installing bed rails, risks and benefits must be reviewed with the resident or representative, consent must be obtained before installation, and residents using bed rails must be reassessed at least quarterly and with a change in condition. Resident #8 was observed with bed rails in the up position on multiple occasions, but the bed rail assessment for the resident documented that the resident was not being considered for bed rails or an assistive device for the bed. Resident #8 had diagnoses including seizures, Parkinson's disease, diabetes, and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. Resident #9 was observed with bed rails up, and the bed rail assessment documented that the resident was being considered for bed rails and that appropriate alternatives were attempted, but the assessment did not answer the question about whether bed rails were recommended at that time. The record did not contain a physician's order, although a consent was signed, and the bed rail assessment was not completed quarterly. Resident #10 was also observed with bed rails up; the assessment documented that alternatives were not attempted, and the record did not contain a consent or physician order. Resident #68 was observed with bed rails up, and the assessment documented that alternatives were not attempted and that the resident had bed rails since 2022, while the last assessment was in 2025; staff stated the resident had bed rails since 2022 and had no assessment after 2025 until returning from the hospital in 01/2026. Resident #71 was observed with bed rails up, and the record showed the last bed rail evaluation was completed in 11/2024, with no physician order and no signed consent. Staff stated bed rail assessments were completed on admission and quarterly, that bed rails were automatically put up on admission, and that consents and physician orders were not obtained at that time.
Medication Administration Errors and Lack of Privacy During Administration
Penalty
Summary
Nursing staff failed to ensure proper competency and medication administration practices when administering IV cefepime to Resident #81. The resident’s physician order documented cefepime 2 grams in 100 ml of dextrose, but during observation on 01/27/26 at 1:50 PM, Staff B, an LPN, obtained cefepime 2 grams in 50 ml of dextrose, connected it to the IV pump, and administered it to the resident. When the medication was compared side-by-side with the physician order, the LPN initially pointed to the documented rate of 100 ml per hour and then agreed that the concentration administered was not the same as ordered. The DON later agreed the nurse should have clarified the order. Review of the pharmacy Proof of Delivery showed the more concentrated cefepime in 50 ml of dextrose had been delivered to the facility on [DATE]. Review of the January 2026 MAR showed twelve different nurses administered the cefepime 2 grams in 50 ml of dextrose without clarifying the order. Facility policies required staff to verify the prescriber order, inspect the medication, and notify pharmacy if there were questions. The facility also failed to follow its medication administration policy during observation of Residents #27 and #100. Resident #27 had diagnoses including depression and psychotic disorder and a BIMS score of 14, and Resident #100 had diagnoses including cancer, bipolar disorder, and psychotic disorder with a BIMS score of 12. On 01/26/26 at 11:07 AM, Staff A, an LPN, entered the room with medications for both residents, handed a medication cup to Resident #27 while the privacy curtain remained open, then immediately proceeded to Resident #100 and handed her a medication cup. Staff A did not explain the medications to either resident and did not provide privacy during the medication administration process.
Medication Administration and Narcotic Reconciliation Errors
Penalty
Summary
The facility failed to ensure safe medication administration for 5 of 8 sampled residents by not ensuring proper narcotic reconciliation and documentation for controlled substances. Facility policy required controlled substances to be documented in accordance with applicable law, but review of the Controlled Medication Utilization Records showed missing administration times or dates for Tramadol for one resident, Oxycodone 10 mg IR for another resident, Oxycodone 5 mg IR for a third resident, and Oxycodone 10 mg IR for a fourth resident. Photographic evidence was obtained during the medication storage review. For one resident, the controlled medication record showed Oxycodone 5 mg IR was received on 01/10/26 and later documented as administered on 01/13/26 at 4:00 PM and 11:19 PM, but the January MAR did not show those administrations. The physician order showed the Oxycodone 5 mg IR had been discontinued on 01/09/26, so there was no active order on 01/13/26. During interview, the Regional Nurse was informed that staff administered Oxycodone 5 mg IR to that resident without an active order. For another resident, an LPN stated she had given a pill that morning and had not signed it out when the narcotic count did not match the packet count.
Failure to Monitor AIMS for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to ensure proper monitoring of psychotropic medications for one resident receiving Seroquel 25 mg by mouth twice daily for psychosis. The resident was admitted with diagnoses including unspecified dementia, psychotic disturbance, major depressive disorder, and anxiety. Facility policy required residents receiving antipsychotic medications to have a baseline AIMS assessment and then ongoing assessments every 3 months as needed while the medication was being used. The resident’s AIMS assessment was documented as completed with a score of 0.0, but the Assistant Director of Nursing acknowledged during interview that the AIMS should be completed quarterly and would have been due in November 2025.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
Medication administration errors were identified during observation, interview, and record review, and the overall medication error rate was 9.38%, exceeding the 5% threshold. For one resident, an LPN administered cefepime 2 gm in 50 ml of dextrose via IV infusion even though the physician order was for cefepime 2 gm in 100 ml of dextrose. When the photo of the IV medication was reviewed, the LPN acknowledged that the concentration given was not correct, and the DON agreed with the finding during the side-by-side review. Additional errors were identified for two other residents during med pass observations. For one resident, an LPN did not administer Locosapent Ethyl during the observed pass even though the MAR showed it was documented as given, and the pharmacist stated the medication had last been reordered in November 2025 as a 30-day supply. For another resident, an LPN did not administer Symbicort inhalation during the observed pass even though the MAR showed it was signed as administered at the same time as the resident's other medications. In both instances, the LPNs stated they had given the medications earlier, but the observed administration and record documentation did not match.
Unattended bedside medications and expired medication storage
Penalty
Summary
Medications were left unattended at the bedside for two residents, and the facility also had expired and improperly stored medications in medication storage areas. Resident #36 had diagnoses including brief psychotic disorder, low vision in the right eye, blindness in the left eye, bilateral hearing loss, and dementia, with a BIMS score of 10 indicating moderate cognitive impairment. Although the resident had scheduled morning doses of Quetiapine 100 mg and Namenda 10 mg ordered for administration by staff, a medicine cup containing two pills was observed left unattended on the bedside table with no nursing staff present. The medications observed matched the resident’s scheduled Quetiapine and Namenda, and the DON later confirmed they should have been administered by staff. No self-medication assessment was documented for this resident. Resident #67 had a BIMS score of 15 and no documented self-medication assessment, yet two medication bottles were observed on the nightstand on two separate occasions. The bottles were identified as Omega Guard and Lecithin, and there were no physician orders for either medication. The resident stated the bottles were taken and locked up. In addition, medication storage observations found two opened, unlabeled insulin vials stored in a zip lock bag in the refrigerator of the medication room, and several bottles of expired medications in a medication cart.
Failure to Perform and Document Weekly Skin Assessments
Penalty
Summary
The facility failed to provide services to prevent skin breakdown for three sampled residents by not performing weekly skin assessments as required by facility policy and care plans. The policy mandated head-to-toe skin inspections upon admission and weekly thereafter, with documentation in the electronic medical record. For one resident, there were no documented skin assessments for several specified weeks, despite the resident having a history of pressure ulcers and a care plan intervention for weekly skin checks. The resident's daughter also reported a lack of communication regarding the resident's status and wounds. Another resident, who was at risk for pressure injury and had active wounds being treated, also did not have weekly skin assessments documented for multiple weeks, including an entire month with no assessments. The care plan for this resident included weekly skin checks as an intervention to address the risk of skin breakdown. Similarly, a third resident with impaired mobility and vascular disease, and an order for weekly skin checks, had multiple weeks where no skin assessments were documented, despite staff signing off on the treatment administration record that the checks were completed. Interviews with nursing staff and the wound care nurse confirmed that the electronic system was designed to prompt nurses when skin assessments were due, and that documentation was to be completed in the electronic record. However, the lack of documented assessments for all three residents indicated that the required skin checks were not consistently performed or recorded, contrary to facility policy and physician orders.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to provide adequate care and services to address the nutritional status of a resident, as evidenced by not following its own weight monitoring policy and not addressing significant weight loss in a timely manner. According to facility policy, residents are to be weighed upon admission, weekly for four weeks, and then monthly, with more frequent assessments if indicated. However, the resident in question was not weighed on the day of admission or within 24 hours, and missed a weekly weight during the first month. The initial weight was recorded four days after admission, and a subsequent weekly weight was not documented as required by policy. Over the course of less than a month, the resident experienced a significant weight loss of 34 pounds, with documented weights showing a loss of 21 pounds in two weeks and a further decline the following week. Despite this, there was no documentation that the weight loss was reported to the physician, and the care plan meeting held during this period did not address the weight loss in detail. The care plan included monitoring for signs of malnutrition and reporting significant weight changes, but these interventions were not implemented as specified. Interviews with staff revealed a lack of clarity and consistency in the process for obtaining and documenting weights, as well as in the communication of significant weight changes to the appropriate clinical staff. The Registered Dietitian was not made aware of the significant weight loss until a week after it was documented, and interventions to address the weight loss were not initiated until several days later. The resident's family also reported difficulty obtaining updates on the resident's status during this period.
Failure to Investigate, Assess, and Report Resident Injury
Penalty
Summary
The facility failed to provide evidence of a thorough investigation, assessment, and appropriate reporting of an incident involving a resident who sustained new bruises of suspected origin. The facility's policy requires that all alleged violations, including abuse or neglect, be thoroughly investigated, with proper documentation and reporting to state and federal agencies as appropriate. In this case, there was no documented assessment of the resident's injury, no incident report, and no evidence of an internal investigation or federal reporting, despite the incident being reported to the state agency. The resident involved was admitted for a nondisplaced intertrochanteric fracture of the right femur and was documented as mentally intact with a BIMS score of 15. The incident in question involved the resident receiving two bruises during a stand pivot transfer from a wheelchair to bed, with the resident stating that the aide was rushed and did not stop when asked. The resident requested that the aide no longer care for her, and the aide was subsequently reassigned. Staff interviews confirmed that the incident was reported to the administrator, but there was no evidence of a clinical assessment of the bruises or a formal incident report being completed. Administrative and clinical record reviews revealed that the facility did not follow its own policy for incident and reportable event management. There was no documentation of the assessment of the resident's injuries, no incident report in the logs, and no evidence of an internal investigation or staff education related to the incident. The administrator was unable to provide documentation of the investigation or reporting, and staff interviews indicated a lack of recall regarding the assessment or documentation of the resident's injuries. The state agency's investigation substantiated the allegations, confirming that the resident sustained physical injuries during the transfer and that the facility did not have the required documentation or evidence of a thorough investigation.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to timely report allegations of abuse to the State Agency for four sampled residents involved in three separate incidents. According to the facility's policy, all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but not later than 2 hours after the allegation is made if abuse or serious bodily injury is involved, or within 24 hours if not. In the first incident, a resident with moderate cognitive impairment was involved in an alleged physical abuse event. The administrator became aware of the incident and reported it to the Abuse Registry within the required timeframe, but did not submit the report to the State Agency until approximately 16 hours after the incident, exceeding the 2-hour requirement. In a second incident, another resident, unable to participate in a cognitive interview, was involved in an alleged physical abuse event. The administrator reported the incident to the Abuse Registry but did not notify the State Agency until more than a day later. In a third incident involving two cognitively intact residents, one as the perpetrator and one as the victim, the administrator again reported the event to the Abuse Registry but delayed reporting to the State Agency by approximately four days. During interviews, the administrator stated he was unaware of the requirement to report such incidents to the State Agency within 2 hours, believing only adult protective services needed to be notified within that timeframe.
Failure to Monitor Hot Beverage Temperatures and Adhere to Wound Care Orders
Penalty
Summary
The facility failed to provide adequate monitoring and management of hot beverage temperatures, leading to a resident sustaining a burn injury. The incident involved a resident with moderate cognitive impairment who was admitted with a displaced commuted fracture of the left tibia. During a dinner meal, the resident requested hot tea, which was placed on his tray by a Certified Nursing Assistant (CNA). The tea was accidentally spilled, resulting in a burn that required hospital evaluation. The facility's investigation revealed inconsistencies in staff accounts and a lack of temperature monitoring for hot beverages, which were often served at temperatures exceeding the facility's stated range. The facility's policy on hot liquids was not effectively implemented, as evidenced by the lack of temperature checks for hot beverages before serving. The Dietary Aide and Cook were unable to provide documentation of temperature checks, and the Food Temperature Log showed multiple instances of hot beverages being served at temperatures above the acceptable range. Despite the policy requiring corrective action for temperatures outside the specified range, there was no evidence of such actions being taken. This oversight contributed to the resident's burn injury, as the hot tea was served at a temperature that posed a risk for scalding. Additionally, the facility failed to adhere to physician-prescribed wound care orders for the resident. The Treatment Administration Record indicated missed treatments on several occasions, and weekly skin checks were not consistently documented. The Wound Care Nurse acknowledged lapses in treatment administration, and the Director of Nursing noted issues with the electronic documentation system. These deficiencies in wound care management further compromised the resident's safety and well-being.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to acknowledge and resolve a grievance for one of the residents, who was admitted with a diagnosis of lumbar radiculopathy. The resident, who was alert and oriented, expressed dissatisfaction with her roommate due to constant yelling and requested a room change. Despite the resident's clear communication of her needs, there was no evidence of a grievance being filed or addressed in the facility's grievance log. Interviews with the Social Services Director and a Licensed Practical Nurse revealed that the resident's complaint was not documented or followed up on. The nurse confirmed the resident's dissatisfaction and her request for a room change but could not recall the method of reporting or any subsequent actions taken. Ultimately, the resident left the facility against medical advice, indicating that her grievance was not resolved, and the facility did not make prompt efforts to address her concerns.
Inadequate and Undignified Care in LTC Facility
Penalty
Summary
The facility failed to ensure care and services were provided in a dignified manner for six of nine sampled residents. The report highlights several instances where residents felt disrespected or neglected by the staff. Resident #26, who has cognitive impairment, reported that some staff members had an attitude, especially during personal care, and mentioned an incident where a nurse refused to provide ibuprofen, citing a lack of order, which was perceived as having a nasty attitude. The Unit Care Coordinator denied having conversations about staff complaints, despite the resident's claims. Resident #49, who is cognitively intact, expressed concerns about understaffing and the rushed nature of care. She recounted an incident where she had an incontinent episode due to delayed response from a CNA and described being pushed over in bed if she did not move quickly enough. Similarly, Resident #54, also cognitively intact, reported staff attitudes suggesting they did not want to be there, with aides ignoring her requests and making inappropriate comments about her bathroom needs. She also mentioned being left exposed during care, which compromised her dignity. Resident #74, with cognitive intactness but physical impairments due to a stroke, described staff as grumpy and unresponsive to his needs, leading to discomfort and hygiene issues. He also faced challenges with nail care, which was neglected, causing physical discomfort. Resident #3, with moderate cognitive impairment, was observed in an uncomfortable position and reported being repositioned multiple times by a CNA who seemed frustrated. Lastly, Resident #372, with moderate cognitive impairment, expressed feeling ignored due to delayed responses to call lights, resulting in accidents. These incidents collectively demonstrate a pattern of inadequate and undignified care within the facility.
Environmental Deficiencies in Facility Units
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment across three units, specifically Units 100, 200, and 400. Observations made over several days revealed multiple environmental concerns, including rust and dust on ceiling vents, peeling paint, and damaged walls in various rooms. Specific issues included rusted and dusty ceiling vents in rooms 103, 105, 111, 115, 123-B, 126-B, 128-B, 203-B, 206-B, and 207-B. Additionally, rooms 104 and 105 had stains and peeling paint, while room 110-B had holes in the walls. Room 112-A had a broken closet door hinge and a torn bathroom seat pad, and room 113-B lacked a string for the light behind the bed. Room 114-B had a torn wheelchair pad, and room 203-B had dirty floors and walls in disrepair. Further observations noted that the hallway by rooms 107-116 had peeling paint on the handrail, exposing wood that could potentially cause splinters. The vinyl base of the wall was also peeling away. The ceiling vent in the laundry room was dusty, and the 400-unit's entrance light was very dusty. During a follow-up tour with the Director of Environmental, the Director of Maintenance, and the Regional President, it was confirmed that the ceiling vents in the 400-unit were very dusty. The Director of Maintenance attributed the wall damage to residents hitting them with wheelchairs or furniture.
Inadequate Staffing Leads to Delayed and Undignified Care
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of residents, as evidenced by multiple complaints from residents and their families. Residents reported that Certified Nursing Assistants (CNAs) were rushing through care, leading to delays in assistance and unmet needs. For instance, a resident mentioned it took a week to get help with a broken fingernail, and another resident expressed fear of being transferred with a mechanical lift due to rushed procedures. The survey revealed that 25 out of 52 residents on a particular unit required two-person assistance, indicating a significant staffing challenge. Residents consistently reported long wait times for call bell responses, with some waiting up to two hours. This delay in response led to incidents of incontinence and undignified care, as residents were unable to receive timely assistance for toileting and repositioning. Several residents expressed feelings of being ignored and undignified care, such as being pushed over in bed if they did not turn quickly enough. Family members also noted insufficient staffing, particularly on weekends, which exacerbated the issue. The Director of Nursing acknowledged the staffing challenges, particularly on weekends, despite claiming there were enough CNAs. The survey highlighted the facility's failure to provide care and services in a dignified manner, as residents reported feeling neglected and undignified due to the lack of staff. This deficiency affected the physical, mental, and psychosocial well-being of the residents, as they were unable to receive the necessary care and attention in a timely and respectful manner.
Failure to Honor Resident's Request for Insulin Sensor Use
Penalty
Summary
The facility failed to honor a resident's request for the use of an insulin sensor, which is a less invasive method for monitoring blood glucose levels compared to the standard finger stick method. The resident, who was admitted to the skilled nursing facility from an associated Independent Living facility, was diagnosed with diabetes and had a BIMS score indicating she was cognitively intact. Despite her request to use the sensor, which was documented by a Nurse Practitioner, the facility continued to perform blood glucose monitoring through finger sticks. The resident expressed her desire to have her insulin sensor replaced and used, as it was more comfortable and less painful than the finger stick method. However, the facility did not replace or use the sensor, and it was noted that the necessary equipment was still at the Independent Living facility. The Unit Care Coordinator acknowledged the situation and indicated that efforts were being made to retrieve the sensor equipment from the neighboring facility.
Failure to Provide Adequate Nail Care for Resident with Hemiparesis
Penalty
Summary
The facility failed to provide proper nail care for a resident with hemiparesis secondary to a stroke, who required substantial to maximum assistance with personal hygiene. The resident, who was cognitively intact, had repeatedly requested assistance with trimming his fingernails over a period of two weeks. Despite having eight opportunities during this time frame, staff did not address the resident's requests, resulting in long fingernails with a black substance underneath and nails on the left hand nearly digging into the palm. The resident expressed frustration during interviews, noting that while his toenails were trimmed regularly, his fingernails were neglected. A CNA, who was responsible for the resident's care, stated that she trims nails as needed but had been on vacation for the past two weeks, indicating a lack of continuity in care. The resident confirmed that the issue of inadequate nail care had been ongoing, not just limited to the recent two-week period.
Medication Administration and Care Deficiencies
Penalty
Summary
The facility failed to adhere to physician-ordered parameters for medication administration for three residents, leading to deficiencies in care. Resident #26 was prescribed midodrine to manage low blood pressure, with specific instructions to withhold the medication if the systolic blood pressure (SBP) exceeded 120. However, the medication was administered on multiple occasions despite the SBP being above the threshold, as documented in the Medication Administration Record (MAR) for July and August 2024. The Director of Nursing (DON) acknowledged the oversight during an interview. Resident #164 experienced a delay in receiving the antibiotic daptomycin, which was last administered by the hospital on 07/23/24. The facility did not provide the antibiotic until 07/28/24, despite the resident's admission on 07/25/24 and the availability of the IV access. Additionally, the facility failed to perform timely dressing changes for the resident's Peripherally Inserted Central Catheter (PICC) line, as required by their policy. The MARs for July and August 2024 lacked documentation of the dressing changes, and the Unit Care Coordinator confirmed the discrepancies during a review. Resident #76 reported delays in receiving medications, which were confirmed by a review of the Medication Administration Audit Report. The resident's medications, including Metformin, Carvedilol, and others, were not administered at the prescribed times on several occasions in July and August 2024. Staff interviews revealed challenges in adhering to medication schedules due to workload, with the DON acknowledging the issue and noting the heavy medication pass on certain units.
Failure to Implement Nutritional Supplements for a Resident
Penalty
Summary
The facility failed to implement nutritional supplements for a resident who was reviewed for nutrition. The resident was admitted with diagnoses including Adult Failure to Thrive, Dementia Without Behavioral Disturbances, Mood Disturbance, and Anxiety. The resident's quarterly MDS assessment indicated moderate cognitive impairment and documented significant weight loss of over 9% within a few months, without being on a prescribed weight-loss regimen. A dietician's progress note from May 2024 recommended adding fortified foods and Med Pass 120 ml three times a day due to a noted weight change. However, a review of the physician's orders from May to August 2024 did not include any orders for Med Pass, and the Registered Dietician confirmed the absence of such an order during an interview.
Failure to Properly Monitor and Administer Tube Feeding
Penalty
Summary
The facility failed to properly monitor and administer the continuous tube feeding for a resident, resulting in the resident not receiving the calculated amount of nutrition and fluids. The resident, who was admitted to the facility with a requirement for all nutrition and fluids to be administered via a feeding tube, had an order for Glucerna 1.5 at 65 ml per hour for 20 hours, totaling 1300 ml, along with 30 ml of water every hour for 20 hours, totaling 600 ml. Observations revealed discrepancies in the administration, with an empty 1000 ml container of Jevity 1.5 noted instead of the prescribed Glucerna, and a water flush bag with 600 ml remaining, indicating a failure to follow the prescribed regimen. Interviews with staff revealed a lack of clarity and adherence to the prescribed feeding regimen. A Licensed Practical Nurse (LPN) admitted to routinely not clearing the volume on the feeding tube pump and noted that the canister was always empty each morning, which was inconsistent with the prescribed amount. The LPN, who was new to the assignment, did not question the discrepancy. The Unit Care Coordinator was unaware of the issue, and the Registered Dietician confirmed the nutritional needs were not met as ordered. This lack of proper monitoring and administration led to the deficiency in care for the resident.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for a resident, identified as Resident #76, who was experiencing chronic pain due to multiple medical conditions, including spinal stenosis, osteoarthritis, and chronic pain syndrome. The resident reported persistent pain in his right shoulder and arm following neck surgery. Despite having physician orders for various pain medications, including Gabapentin, Lidoderm patches, Biofreeze patches, and Acetaminophen, the medications were not administered at the prescribed times. The Medication Administration Audit Report indicated significant delays in administering these medications, with instances of missed doses and late applications, particularly for Gabapentin and the topical patches. Interviews with facility staff revealed systemic issues contributing to the deficiency. An LPN reported that the resident had been on stronger pain medications previously, but due to side effects, these were discontinued, leaving the resident with less effective pain management options. A newly employed RN admitted to struggling with the workload, stating that it was challenging to administer medications within the required time frame due to the number of patients and logistical issues, such as residents being in different locations during medication rounds. The resident confirmed that he did not refuse medications but noted that staff often forgot to apply patches after his showers, leading to increased pain levels.
Medication Security and Expiration Issues
Penalty
Summary
The facility failed to secure medications properly, as evidenced by an incident involving a resident who had dispensed and open medications at their bedside. The resident, who was cognitively intact with a BIMS score of 14/15, had medications administered orally in the mornings. During an interview, the resident was observed with medications on a napkin, explaining that they were waiting for a nurse to return with a medicine cup. The resident expressed suspicion about one of the medications, leading them to pour the medications onto a napkin. The nurse later returned, clarified the medications with the resident, and the resident took the medications in the nurse's presence. Additionally, the facility failed to ensure medication carts were free of expired medications. During a medication storage review, expired medications were found in one of the medication carts, including two bottles of Ferrex 150 mg and a bottle of Ibuprofen 200 mg, all expired in July 2024. It was discovered that a resident had been administered the expired Ferrex 150 mg on two consecutive days. This oversight in medication management could potentially affect the resident's health, as they were prescribed the expired medication.
Inadequate Protein Portion Served to Residents
Penalty
Summary
The facility failed to provide an adequate protein portion for residents consuming a regular diet during lunch on 08/07/24. The menu for that day included kielbasa with peppers and onions, with the diet spreadsheet indicating a serving size of 4 ounces of kielbasa and 2 ounces of vegetables. However, the production recipe instructed to serve 4 ounces of sausage with 3 ounces of vegetables. During the lunch service, the cook used a 4-ounce ladle to serve the kielbasa and vegetables, resulting in each resident receiving approximately 6 slices of kielbasa. Upon weighing the average portion of 6 slices, it was found to be only 2.4 ounces, which was less than the required 4 ounces of protein. Both the cook and the Certified Dietary Manager acknowledged that the protein portion served was inadequate. This deficiency had the potential to affect 70 residents on a regular diet, including several sampled residents, as the facility did not meet the nutritional needs as outlined in their menu and dietary guidelines.
Latest citations in Florida
Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
