Park Meadows Healthcare & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Gainesville, Florida.
- Location
- 3250 Sw 41st Place, Gainesville, Florida 32608
- CMS Provider Number
- 105193
- Inspections on file
- 25
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Park Meadows Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
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 staff did not consistently follow physician orders for several residents, including an RN repeatedly holding ordered insulin without required physician notification, and an LPN crushing and administering a delayed-release medication without clarifying its appropriateness. Wound care orders for daily and three-times-weekly dressing changes were not carried out as prescribed, with dressings left unchanged for days and staff unable to account for missed treatments. A resident ordered to wear an AFO during transfers and when out of bed was frequently observed without it, while documentation of application was incomplete and CNAs reported not consistently applying or keeping the device on. Another resident on G-tube feeding had feeding and water setups used beyond the ordered timeframe, and an LPN restarted tube feedings and administered medications without checking gastric residuals as required by the physician order.
The facility failed to maintain accurate, resident-centered comprehensive care plans aligned with current assessments and communication needs. One resident with a nephrostomy was incorrectly care planned for a colostomy, while another resident continued to be care planned as a smoker despite no longer smoking or leaving bed to smoke. A third resident, assessed as mostly independent and able to perform personal hygiene such as shaving, still had a care plan stating dependence for all ADLs. Additionally, a Spanish-speaking resident who did not understand English and required interpreter services had no communication focus in the care plan, even though staff and clinical documentation acknowledged the language barrier and use of translation methods.
A resident with orders for multiple medications, including probiotics, vitamin C, Eliquis, Famotidine, and insulin (Glargine and Apidra), had several scheduled doses in one month with no corresponding entries on the MAR. Because the resident disliked certain LPNs, nurses informally split responsibilities so that one nurse administered medications while another documented them, leading to missed documentation when the documenting LPNs forgot or were distracted. This practice conflicted with facility policy requiring the staff providing care to record medications administered, resulting in incomplete and inaccurate clinical records for the resident.
The facility was found to have an unsanitary environment across all hallways, with trash and debris present and no housekeeping staff observed during the inspection. Residents expressed dissatisfaction with the housekeeping services, and the Administrator confirmed the lack of adherence to the cleaning schedule.
A resident with a mechanical soft diet order was served a hotdog, which did not meet dietary restrictions, leading to a finding of neglect. Despite being informed by an RN, the LPN did not remove the food item, and a CNA cut the hotdog for the resident. The resident had a complex medical history, including dysphagia, increasing the risk of aspiration. Staff interviews revealed a lack of adherence to diet verification procedures, contributing to the incident.
A resident with a mechanical soft diet order was inappropriately served a hotdog, despite staff being aware of the dietary restriction. The LPN retrieved the hotdog without verifying the resident's diet, and neither the LPN nor the RN removed the food after realizing the error. The CNA cut the hotdog, but it still did not meet the mechanical soft diet requirements. This led to Immediate Jeopardy due to the facility's failure to provide a safe environment and adequate supervision.
A resident with a mechanical soft diet was improperly served a hotdog, despite staff being aware of the dietary restriction. The LPN failed to verify the diet, and the RN did not remove the food after identifying the error. The resident's complex medical history, including dysphagia, increased the risk of harm, leading to a determination of Immediate Jeopardy.
A resident with specific dietary needs was given a hotdog by an LPN without verifying the diet order, despite an RN's warning. The resident's diet required a Controlled Carbohydrates (CCHO) diet with Mechanical Soft texture. The staff failed to remove the inappropriate food item, leading to a determination of neglectful behavior and Immediate Jeopardy due to the facility's failure to implement policies and procedures for therapeutic diets.
The facility failed to serve food at an appetizing temperature, as evidenced by resident complaints and a test tray observation. Residents reported receiving cold food, and a test tray showed food temperatures below the optimal level. The facility's policy requires food to be served at a safe and appetizing temperature, which was not adhered to, resulting in the deficiency.
The facility failed to maintain a clean and secure environment in two shower rooms and the memory care unit. A resident reported mold in the shower rooms, which was confirmed by observations of black substances on the ceilings. In the memory care unit, a door had a gap due to a plywood repair, exposing the interior to the outside. The Maintenance Director was unaware of these issues, despite a policy for maintenance work orders.
The facility failed to implement a comprehensive care plan for a resident at risk for falls, as only one fall mat was placed instead of the required two. Additionally, another resident's care plan lacked focus on incontinence care, despite documented needs and staff observations. These deficiencies were contrary to the facility's policy on comprehensive assessments and care plans.
A resident did not receive blood pressure medication according to the physician's order, which specified holding the medication if the SBP was greater than 110. The medication was administered multiple times when the SBP exceeded this parameter. Interviews with the DON and Medical Director confirmed the error, but no negative impact on the resident's health was observed.
Two residents in an LTC facility did not receive dietary services as prescribed by their physicians. One resident, with Alzheimer's and other health issues, was not given the required frozen nutritional treat with meals, despite a physician's order. Another resident, with diabetes and renal disease, received insufficient meal portions, contrary to the prescribed double protein diet. Both cases highlight a failure to adhere to the facility's dietary policies, as confirmed by registered dietitians.
A facility failed to provide timely laboratory services for a resident, missing scheduled tests for Hemoglobin A1c and Depakote levels as ordered by the physician. The oversight was confirmed by the DON, who noted that the tests were conducted only after the issue was identified. The facility's policy requires timely diagnostic services, which was not followed in this instance.
A facility failed to accurately document the provision of a frozen nutritional treat for a resident with a physician's order due to weight loss. Observations showed the resident did not receive the treat during meals, despite the MAR indicating otherwise. Interviews with the DON and an LPN revealed expectations for accurate documentation and meal checks, yet discrepancies were noted.
The facility failed to ensure proper infection control practices, as observed in the actions of a CNA and an LPN who did not sanitize equipment or perform hand hygiene during medication administration. Additionally, a clean linen cart was improperly used to store personal items, violating the facility's infection control policies.
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.
Failure to Follow Physician Orders for Medications, Wound Care, Orthotic Use, and Enteral Feeding
Penalty
Summary
The deficiency involves multiple failures by nursing and therapy staff to follow physician orders for medications, treatments, devices, and enteral nutrition. One resident with diabetes had an order for daily Insulin Glargine with instructions to notify the physician if blood sugar was less than 70 mg/dL. Review of the MAR showed that an RN repeatedly held the insulin on numerous dates when blood sugars were between 60 and 117 mg/dL, including several instances where no blood sugar was documented at all, and the RN stated she misread the order and did not recall notifying the physician. Another resident had an order for a delayed-release oral medication, Zunveyl 10 mg twice daily, with a general order allowing medications to be crushed unless contraindicated. An LPN crushed the delayed-release tablet and administered it without first clarifying with the provider or pharmacy, later acknowledging that the medication was delayed release and that she should have obtained clarification. The deficiency also includes failures to follow wound care orders for residents with skin conditions. One resident who had a dermatology biopsy on the left side of the neck had a physician order for daily wound care on the day shift for seven days, including washing with soap and water, applying petroleum jelly, and covering with a nonstick bandage. Observations on two consecutive days showed the same dressing dated several days earlier still in place, and the resident reported that the dressing had not been changed. Nursing staff interviewed either did not recall the dressing date, stated they did not see dressing change orders, or could not recall what happened on the ordered wound care day. Another resident with a right knee wound from a fall at home had an order for wound care three times weekly on the day shift (Tuesday, Thursday, Saturday). The wound care nurse stated she worked on the relevant Saturday but did not perform the ordered dressing change because the resident was up, and the DON stated staff should follow physician orders and perform wound care as ordered. Additional deficiencies occurred in the implementation of therapy-related and enteral feeding orders. One resident with an order for a right ankle orthosis (AFO) to be applied during transfers and when out of bed was repeatedly observed in a wheelchair and in bed without the AFO, while the device was stored in the closet. The task list showed documentation of AFO application for several days early in the month but no entries on later dates when the resident was observed without the device. Therapy and nursing staff described that restorative aides were to apply the AFO, but a restorative CNA reported they were not applying it and were instead working with a hand splint, and a CNA stated she sometimes removed the AFO when the resident was sitting because she thought he did not like to wear it. Another resident receiving enteral nutrition via G-tube had a physician order for Jevity 1.5 at a specified rate and schedule, with an order to check tube residual prior to feeding, medications, and flushes, and to hold feeding and notify the physician if residual was 100 mL or more. Observations showed the feeding bottle and attached water bag in use beyond 24 hours, and an LPN stated she believed the setup was good for 24 hours and based changes on what was left in the bottle. When restarting the feeding, the LPN set the pump according to the order but did not check for residual, and she confirmed she did not check residuals prior to medication administration or initiation of feeding, despite the physician order and facility policy requiring verification of tube placement and residual volumes.
Failure to Maintain Accurate, Resident-Centered Comprehensive Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain accurate, resident-centered comprehensive care plans consistent with residents’ assessed needs and conditions. For one resident with hemiplegia, overactive bladder, and a nephrostomy catheter, the care plan incorrectly documented a focus on an artificial bowel opening (ostomy/colostomy) with related bowel-output interventions, even though the resident did not have a colostomy. The MDS LPN and the DON both confirmed that the resident had a nephrostomy, not a colostomy, indicating the care plan did not reflect the resident’s actual medical status. Another resident with pulmonary fibrosis, morbid obesity, malnutrition, feeding difficulties, malignant neoplasm of the glottis, dysphagia, and GERD had a care plan focus indicating the resident was a smoker/tobacco user, initiated and last revised several years earlier. Interviews with the resident, an LPN, and the DON confirmed that the resident no longer smoked, did not get out of bed or go outside to smoke, and had not had a recent smoking evaluation because the resident was no longer an active smoker. Despite this, the care plan still identified the resident as a smoker, showing it had not been updated to reflect the resident’s current status. A third resident with hemiplegia, seizures, dementia with behavioral disturbance, and restlessness/agitation had a care plan focus stating the resident had self-care deficits and required assistance with all ADLs, including dressing, grooming, and bathing. However, interviews with nursing staff and the resident indicated the resident was mostly independent, steady, moved independently, and shaved independently after obtaining a razor from CNAs. The MDS assessment completed the prior month documented the resident as independent for personal hygiene, but the care plan, last updated many months earlier, still showed a need for assistance with all ADLs. Additionally, a Spanish-speaking resident who did not understand English and required an interpreter had no communication focus in the care plan, despite documentation in a skin exam note that a translator app and the resident’s son were used for communication, and staff interviews confirming the resident primarily spoke Spanish. The MDS LPN and DON acknowledged that care plans were not up to date and that a communication focus needed to be added, demonstrating that the care plans did not incorporate identified communication needs or align with the facility’s policy requiring culturally competent care planning.
Incomplete Medication Administration Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for one resident related to medication administration. Physician orders for this resident included Acidophilus 100 mg capsules twice daily, Ascorbic Acid 500 mg tablets twice daily, Eliquis 5 mg twice daily for unspecified atrial flutter, Famotidine 20 mg twice daily for GERD, Insulin Glargine 35 units subcutaneously twice daily for diabetes in a dialysis patient, and Apidra SoloStar 8 units subcutaneously before meals for type 2 diabetes with complications. Review of the resident’s MAR for December showed missing documentation entries for multiple scheduled doses of these medications, including Acidophilus, Ascorbic Acid, Eliquis, Famotidine, Insulin Glargine, and Apidra at specified afternoon/evening administration times. Interviews with nursing staff revealed that the resident did not like certain LPNs, leading to an informal practice where one nurse would administer the medications while another nurse was responsible for documenting them on the MAR. One LPN stated she gave all of the resident’s medications on a specific date and expected another LPN to document them, while that LPN acknowledged she was supposed to document the medications but must have forgotten. Another LPN reported that, due to the resident’s verbal abuse, another nurse administered the medications while she pulled the insulin and verified with the other nurse that the medications were given, but she believed she became distracted and failed to sign off on the MAR. The facility’s policy on Charting and Documentation required that medications administered and services performed be recorded in the resident’s clinical record by the staff providing care, but this was not followed, resulting in incomplete and inaccurate medical records for the resident.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain an orderly and sanitary environment across all four hallways (100, 200, 300, and 400), as observed during a tour on March 29, 2025. Trash and debris were noted in these areas, with no housekeeping carts present during the inspection. Specific observations included significant debris near the exit to the smoking patio on the 100 hallway, consisting of leaves, grass, and small pieces of trash. Interviews with residents revealed dissatisfaction with the housekeeping services, with one resident describing it as a 'joke.' Further observations confirmed the continued presence of trash and debris, and a large, uncovered cart filled with soiled linens and trash was noted, emitting a foul odor. Additionally, a brownish dried liquid was observed on the wall in the 100 hallway. The Administrator confirmed the unsanitary conditions and acknowledged that the housekeeping staff did not work on the morning of the inspection. The Administrator stated that housekeeping personnel are expected to follow a checklist for cleaning rooms and common areas, but this schedule was not adhered to. The absence of housekeeping staff and the failure to follow the cleaning checklist contributed to the unclean environment observed during the survey.
Failure to Adhere to Dietary Restrictions Leads to Neglect
Penalty
Summary
The facility failed to protect a resident from neglect by not adhering to the prescribed dietary requirements. A resident, who had a physician's order for a mechanical soft diet, was served a hotdog and hotdog bun, which did not comply with the dietary restrictions. Despite being informed by a Registered Nurse (RN) that the resident should not have a hotdog, the Licensed Practical Nurse (LPN) did not remove the food item. The resident attempted to consume the hotdog, and a Certified Nursing Assistant (CNA) further facilitated this by cutting the hotdog in half, although this did not meet the mechanical soft diet requirements. The resident involved had a complex medical history, including chronic obstructive pulmonary disease, heart failure, muscle weakness, malnutrition, and dysphagia, which increased the risk of aspiration and choking. The Speech Therapy evaluation indicated the resident was on a mechanical soft diet due to decreased oral function and risk of aspiration. Despite these clear dietary restrictions, the staff failed to verify the resident's diet before serving the hotdog, and the error was not corrected even after it was identified. Interviews with staff revealed a lack of adherence to the facility's policies and procedures regarding diet verification and neglect prevention. The LPN admitted to freezing and not removing the plate due to the presence of a surveyor, while the RN assumed the LPN would take corrective action. The Cook and Food Service Director acknowledged that the procedure for verifying diet orders was not followed, contributing to the incident. The facility's failure to implement its policies and procedures for neglect led to the determination of Immediate Jeopardy.
Removal Plan
- Resident #45 was re-evaluated by the licensed nurse and the speech therapist.
- Resident #45's chest x-ray was completed.
- Residents were interviewed regarding abuse and neglect, and skin evaluations for residents who are not able to be interviewed were carried out to identify abuse or neglect.
- Facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out.
- The DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet.
- A root cause analysis was conducted and Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets.
- The facility Administrator, Director of Nursing, and Regional Nursing Consultant were educated by the Chief Nursing Officer Consultant on the components of abuse, neglect, exploitation, and injury of unknown origin to include reporting requirements.
- A performance improvement plan for abuse and neglect was developed and executed with the QAPI Committee and Medical Director.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery.
- 227 out of 233 facility staff members (112 out of 112 certified nursing assistants, 37 out of 38 licensed practical nurses, 14 out of 15 registered nurses, and 16 out of 16 dietary staff members) were reeducated on the accuracy of diets and abuse, neglect, exploitation, and injury of unknown origin.
- The facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process.
Inappropriate Diet Served to Resident with Mechanical Soft Diet Order
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards when a resident was served an inappropriate therapeutic diet. The incident involved a resident who had a physician's order for a mechanical soft diet due to conditions including dysphagia and risk for aspiration. Despite this, the resident was served a hotdog, which was not suitable for their dietary needs. The error was identified by a registered nurse, but neither the nurse nor the licensed practical nurse who served the meal took action to remove the inappropriate food item. The resident, who had a history of chronic obstructive pulmonary disease, heart failure, and other health issues, was observed in the dining room requesting an alternative food item. The licensed practical nurse retrieved a hotdog from the kitchen without verifying the resident's dietary restrictions. Although the registered nurse informed the licensed practical nurse that the resident should not have a hotdog, the food was not removed, and the resident attempted to consume it. A certified nursing assistant later cut the hotdog in half, but this did not meet the requirements of a mechanical soft diet. Interviews with staff revealed a lack of adherence to procedures for verifying and serving appropriate diets. The cook did not verify the resident's diet due to the absence of a meal ticket, and the licensed practical nurse did not follow the protocol of checking the diet before serving the food. The registered nurse, overwhelmed with other tasks, assumed the licensed practical nurse would correct the mistake but did not intervene directly. This series of actions and inactions led to the determination of Immediate Jeopardy, highlighting the facility's failure to provide adequate supervision and a safe environment for the resident.
Removal Plan
- Resident #45 was re-evaluated by the licensed nurse and the speech therapist.
- Resident #45's chest x-ray was completed.
- Facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out.
- The DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet.
- A root cause analysis was conducted and Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery.
- 227 out of 233 facility staff members (112 out of 112 certified nursing assistants, 37 out of 38 licensed practical nurses, 14 out of 15 registered nurses, and 16 out of 16 dietary staff members) were reeducated on the accuracy of diets.
- The facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process.
Failure to Implement Dietary Policies Leads to Immediate Jeopardy
Penalty
Summary
The facility administration failed to effectively manage resources to ensure the highest practicable physical well-being of each resident, specifically by not implementing policies and procedures related to neglect and therapeutic diets. A resident with a physician's order for a mechanical soft diet was served a hotdog, which was not in compliance with their dietary needs. Despite being informed by a registered nurse that the resident should not have a hotdog, the licensed practical nurse did not remove the food item, and a certified nursing assistant further facilitated the resident's consumption by cutting the hotdog in half. The resident in question had a complex medical history, including chronic obstructive pulmonary disease, heart failure, muscle weakness, and dysphagia, which increased their risk for aspiration and choking. The resident had been evaluated by a speech therapist and was on a mechanical soft diet due to these risks. However, the staff involved failed to verify the resident's dietary needs before serving the hotdog, and even after recognizing the error, they did not take corrective action to remove the inappropriate food item. Interviews with staff revealed a lack of adherence to established procedures for verifying and serving diets. The licensed practical nurse did not verify the resident's diet with the kitchen staff, and the cook did not follow the procedure of checking the diet ticket or verifying the diet with the nurse. The registered nurse, although aware of the dietary error, did not intervene effectively to prevent the resident from consuming the inappropriate food. This series of actions and inactions led to a determination of Immediate Jeopardy due to the potential harm posed to the resident.
Removal Plan
- Resident #45 was re-evaluated by the licensed nurse and the speech therapist.
- Resident #45's chest x-ray was completed.
- Residents were interviewed regarding abuse and neglect, and skin evaluations for residents who are not able to be interviewed were carried out to identify abuse or neglect.
- Facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out.
- The DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet.
- A root cause analysis was conducted and Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets.
- The facility Administrator, Director of Nursing, and Regional Consultant were educated by the Chief Nursing Officer Consultant on the components of abuse, neglect, exploitation, and injury of unknown origin to include reporting requirements.
- A performance improvement plan for abuse and neglect was developed and executed with the QAPI Committee and Medical Director.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery.
- 227 out of 233 facility staff members were reeducated on the accuracy of diets and abuse, neglect, exploitation, and injury of unknown origin.
- Education was completed by the Regional Nurse Consultant with the Administrator and the DON to review job descriptions and the components of QAPI.
- The facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process.
Failure to Implement Therapeutic Diet Policies
Penalty
Summary
The facility failed to utilize the Quality Assessment and Performance Improvement (QAPI) process effectively, leading to a deficiency in implementing policies and procedures for neglect and therapeutic diets. On October 15, 2024, a resident requested an alternative food item from a Licensed Practical Nurse (LPN) in the dining room. The LPN provided a hotdog and hotdog bun without verifying the resident's diet in the kitchen. A Registered Nurse (RN) identified the error, stating that the resident was not supposed to have a hotdog, but neither the RN nor the LPN removed the food item from the resident. The resident, who had a Controlled Carbohydrates (CCHO) diet with Mechanical Soft texture and thin consistency, was observed picking up the hotdog and placing it in his mouth, although he did not chew or swallow it. A Certified Nursing Assistant (CNA) then cut the hotdog in half, allowing the resident to attempt to consume it again. The resident's medical record indicated multiple diagnoses, including chronic obstructive pulmonary disease, heart failure, and diabetes, which necessitated adherence to a specific diet. The facility's failure to act upon the identified dietary error and remove the inappropriate food item was determined to be neglectful behavior. The incident was classified as Immediate Jeopardy due to the systemic breakdown in implementing the facility's policies and procedures, which was not addressed through the QAPI process. The Nursing Home Administrator acknowledged the failure to act and recognized the neglectful nature of the staff's inaction.
Removal Plan
- Resident #45 was re-evaluated by the licensed nurse and the speech therapist.
- Resident #45's chest x-ray was completed.
- Residents were interviewed regarding abuse and neglect, and skin evaluations for residents who are not able to be interviewed were carried out to identify abuse or neglect.
- Facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out.
- The DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet.
- A root cause analysis was conducted and Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets.
- The facility Administrator, Director of Nursing, and Regional Consultant were educated by the Chief Nursing Officer Consultant on the components of abuse, neglect, exploitation, and injury of unknown origin to include reporting requirements.
- A performance improvement plan for abuse and neglect was developed and executed with the QAPI Committee and Medical Director.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery.
- 227 out of 233 facility staff members were reeducated on the accuracy of diets and abuse, neglect, exploitation, and injury of unknown origin.
- Education was completed by the Regional Nurse Consultant with the Administrator and the DON on the components of QAPI.
- The facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process.
Deficiency in Serving Food at Appetizing Temperature
Penalty
Summary
The facility failed to ensure that food served to residents was at an appetizing temperature, as evidenced by multiple resident complaints and a test tray observation. Resident #105 reported that breakfast trays often arrived late, resulting in cold food. Similarly, Resident #109 also complained about receiving cold food. During a test tray observation, food temperatures were measured using a calibrated thermistor digital thermometer. The food, which included ravioli with meat sauce and Italian green beans, was placed on a tray and in an insulated cart at 12:10 PM and left the kitchen at 12:14 PM. By the time the last resident began eating at 12:42 PM, the food temperatures were recorded at 109 degrees Fahrenheit for the ravioli and 89.6 degrees Fahrenheit for the green beans, both below the optimal serving temperature. The Registered Dietitian confirmed that the optimal food temperature when served should be above 110 degrees Fahrenheit, and the kitchen ensures food is above 135 degrees when initially placed on plates. The facility's policy, last reviewed on January 31, 2024, mandates that food and drink be nutritious, palatable, attractive, and served at a safe and appetizing temperature. Despite these guidelines, the facility did not adhere to its policy, resulting in the deficiency noted during the survey.
Facility Fails to Maintain Clean and Secure Environment
Penalty
Summary
The facility failed to maintain a clean, orderly, and comfortable environment in two shower rooms and the memory care unit. During an interview, a resident reported that the shower rooms were consistently dirty and moldy. Observations confirmed the presence of a black substance in a circular pattern on the ceiling over the shower area and brown discoloration on the ceiling leading to the shower area in the 100 Hall Shower Room. Additionally, a line of black substance spots was observed on the ceiling over the area leading into the shower in the 500 Hall Shower Room. The Maintenance Director was unaware of these issues. In the memory care unit, a hallway exterior exit door had a large piece of plywood attached where glass should have been, with a 2-inch gap between the plywood and the metal door frame at the bottom, exposing the interior to the outside. During an observation with the Maintenance Director and Housekeeper Supervisors, it was confirmed that the duct tape used to secure the plywood had come off, leaving a gap. The Maintenance Director acknowledged he was unaware of the gap and the tape's failure. The facility's policy on maintenance work orders was reviewed, indicating a system for requesting and completing maintenance, but it appears this system was not effectively implemented in these instances.
Deficiencies in Care Plan Implementation and Development
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident identified as being at risk for falls. Observations on multiple occasions revealed that the resident had only one fall mat placed on the left side of the bed, despite a physician's order and care plan specifying that fall mats should be placed on both sides. This discrepancy was confirmed during interviews with a registered nurse and the Director of Nursing, who acknowledged the expectation to follow physician orders and care plans. Additionally, the facility did not develop a comprehensive care plan for another resident who was occasionally incontinent of bowel and bladder. The resident's care plan lacked a focus on incontinence care, despite the resident's condition being documented in the Minimum Data Set and physician orders for medication related to urinary retention. Interviews with staff indicated that the resident often refused to be cleaned up, yet this issue was not addressed in the care plan, contrary to the facility's policy on comprehensive assessments and care plans.
Failure to Administer Blood Pressure Medication as Prescribed
Penalty
Summary
The facility failed to administer blood pressure medication as prescribed by the physician for a resident. The physician's order for the resident, dated March 6, 2024, specified that Midodrine HCl Tablet 10 mg should be given every 8 hours for hypotension, with instructions to hold the medication if the systolic blood pressure (SBP) was greater than 110. However, the Medication Administration Record (MAR) for October 2024 showed that the medication was administered multiple times when the resident's SBP was above the specified parameter, including readings of 116, 122, 126, 124, 114, 127, 125, 123, and 112. Interviews with the Director of Nursing (DON) and the Medical Director confirmed that the medication was given outside the prescribed parameters. The DON acknowledged the error but noted that the resident had recently attended a cardiology appointment and was reportedly fine, with no negative impact observed. The Medical Director also reviewed the situation and revised the parameters, stating that the resident's health was stable and monitored, with no adverse effects from the medication administration error.
Failure to Provide Prescribed Dietary Services
Penalty
Summary
The facility failed to provide dietary services as prescribed by the physician for two residents, leading to deficiencies in their nutritional care. Resident #43, who has a history of Alzheimer's dementia, feeding difficulties, and other health issues, was observed multiple times without receiving the prescribed frozen nutritional treat with meals, despite a physician's order for it due to weight loss. The resident's care plan indicated a risk for alteration in nutrition and hydration, yet the prescribed dietary interventions were not consistently followed, as evidenced by the absence of the nutritional treat during meal observations. Resident #128, who has a diagnosis of type 2 diabetes mellitus, end-stage renal disease, and other health conditions, was also not provided with meals that met the prescribed dietary requirements. The resident's physician order specified a renal controlled carbohydrate diet with double meat/protein with meals, but observations revealed insufficient meal portions, such as a half peanut butter and jelly sandwich for lunch, which was deemed inadequate by the registered dietitian. The resident experienced significant weight loss, further indicating that the dietary needs were not being met as prescribed. The facility's policy and procedure for providing diets to meet the needs of each resident were not adhered to, as both residents did not receive meals consistent with their physician's orders. The registered dietitians acknowledged the inadequacy of the meals provided, highlighting a failure in the facility's food and nutrition services to ensure that residents' nutritional and hydration needs were met according to their individual care plans and physician orders.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide necessary laboratory services for a resident, specifically for the monitoring of Hemoglobin A1c and Depakote levels, as ordered by the physician. The physician's order, dated June 18, 2024, required these tests to be conducted every three months. However, a review of the resident's medical record revealed no documentation of the laboratory tests being performed in September 2024. During an interview, the Director of Nursing confirmed that the lab work was not completed as scheduled and stated that the blood was drawn on the morning of October 17, 2024, after the oversight was discovered. The facility's policy, last reviewed on January 31, 2024, mandates the provision of timely laboratory, radiology, and diagnostic services when ordered by a physician or other qualified healthcare professionals. This policy was not adhered to in the case of the resident, leading to a deficiency in meeting the resident's healthcare needs.
Failure to Accurately Document Nutritional Supplementation
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for a resident identified as having a physician's order for a frozen nutritional treat with meals due to weight loss. Observations over several days revealed that the resident did not receive the frozen nutritional treat during meals, despite the physician's order. Specifically, during meal observations on multiple occasions, the resident was noted to be eating various meals without the prescribed frozen nutritional treat. The Medication Administration Record (MAR) inaccurately documented that the resident received the frozen nutritional treat at specified times, which was contradicted by direct observations. Interviews with the Director of Nursing and a Licensed Practical Nurse highlighted expectations for accurate documentation and meal tray checks, yet discrepancies persisted. The facility's policy on charting and documentation mandates that services provided to residents be accurately recorded, which was not adhered to in this case.
Infection Control Deficiencies in Hand Hygiene and Linen Handling
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during medication administration and the handling of medical equipment and clean linens. During observations, a Certified Nursing Assistant (CNA) did not sanitize a vital sign machine between residents, using it on multiple residents without cleaning. The CNA acknowledged the oversight, stating that disinfecting wipes were not available on their cart at the time. Additionally, a Licensed Practical Nurse (LPN) was observed not performing hand hygiene before and after administering medications to residents, even after donning and doffing gloves. The LPN admitted to not using hand sanitizer between residents, which is against the facility's hand hygiene policy. Furthermore, the facility did not maintain a clean storage environment for linens. A clean laundry cart was found with a bottle of coke and a bag of chips among the clean sheets, which was confirmed by the Housekeeping Supervisor as inappropriate. The facility's policy on handling linens to prevent infection was not adhered to, as evidenced by the improper storage of personal items on the clean linen cart.
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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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