Rehabilitation Center Of The Palm Beaches, The
Inspection history, citations, penalties and survey trends for this long-term care facility in West Palm Beach, Florida.
- Location
- 301 Northpointe Parkway, West Palm Beach, Florida 33407
- CMS Provider Number
- 105039
- Inspections on file
- 22
- Latest survey
- March 31, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Rehabilitation Center Of The Palm Beaches, The during CMS and state inspections, most recent first.
Surveyors found multiple unsealed conduit penetrations and improper fire stopping materials in the fire and smoke barriers of an electrical room. The facility could not provide documentation that the materials used were approved for fire stopping, and several areas had visible breaches in the rated walls, indicating noncompliance with NFPA 101 standards.
Surveyors found that after the removal of a drop ceiling in an electrical room, two sprinkler heads were left too far below the new ceiling, resulting in inadequate sprinkler coverage and noncompliance with NFPA 101 and NFPA 13 requirements. The Maintenance Director confirmed the findings during the facility tour.
A facility failed to honor a resident's shower schedule, as requested by the resident's representative. The resident, with severe cognitive impairment and dependent on care, was scheduled for showers twice a week. However, records showed the resident received bed and tub baths instead. A note from the resident's sister requested adherence to the shower schedule, but staff interviews confirmed the lack of showers and absence of a tub in the facility.
A facility failed to accurately document the discharge status of a resident who was discharged home, as the MDS assessment incorrectly recorded the discharge as to a 'Short-Term General Hospital'. The resident, with multiple diagnoses, was discharged with all necessary instructions and medications, but the error was confirmed by the MDS Coordinator, who planned to update the assessment.
The facility failed to follow physician orders for several residents, including not applying prescribed antifungal cream, not administering blood pressure medication as needed, and not arranging a urology consultation. These deficiencies were due to lapses in medication management, inconsistent monitoring, and lack of follow-up care.
A resident with severe cognitive impairment was not provided adequate hydration due to staff mishandling her fluid restriction orders. Despite being on a 1200 ml/day fluid restriction, her juices were frequently discarded by aides, leaving her with dry lips and feeling depressed. The resident's complaints were confirmed during an observation where she discussed the issue with the MDS coordinator, who promised to inform the aides not to remove her juice.
A facility failed to ensure timely physician visits for a resident with a catheter. The resident, who had mild cognitive impairment and was dependent on staff for ADLs, experienced a significant gap in physician evaluations, with no visits recorded between late August and early November. This deficiency was acknowledged by the DON during an interview.
A resident with mild cognitive impairment and dependence on staff for ADLs did not receive timely physician visits following readmission from the hospital, as required by regulation. Review of records showed a gap in physician evaluations, which was acknowledged by the DON.
The facility did not meet the required daily average of 2.0 CNA hours per resident on multiple days during the first quarter of FY 2025, with daily averages falling below the standard. The DON acknowledged these findings during the survey. This constitutes a Class III deficiency.
The facility did not properly post daily nursing staff information, as required, by listing only names without titles or unit assignments. This made it unclear which nurses or CNAs were responsible for specific residents, and both surveyors and residents could not determine staff assignments from the posted information. The ADON acknowledged these deficiencies.
A resident who was fully dependent for care did not receive scheduled showers as requested by her representative, despite a posted note and care plan specifying shower days. Instead, the resident received bed baths and tub baths, with staff and DON confirming the lack of shower documentation and the absence of a tub in the facility.
Surveyors found that the facility failed to ensure a resident on fluid restriction received her allowed fluids, did not provide a prescribed skin cream to another resident due to lack of supply, and did not consistently monitor or document blood pressure for a resident with hypertension as ordered. Additionally, a required follow-up consultation for another resident was not completed or documented.
A resident with multiple diagnoses was discharged home as documented in care plans, progress notes, and social services records. However, the MDS discharge assessment incorrectly recorded the discharge status as 'Short-Term General Hospital' instead of home. The MDS Coordinator confirmed the error and indicated the assessment would be updated.
Failure to Maintain Fire/Smoke Barrier Integrity in Electrical Room
Penalty
Summary
During an unannounced Fire & Life Safety revisit survey, surveyors observed that the facility failed to maintain proper fire and smoke barrier construction in accordance with NFPA 101 standards. Specifically, in Electrical Room #6, there were five open conduit penetrations through the south side 1-hour fire rated wall and three penetrations through the north side smoke wall. Additionally, thirteen areas on the east and south side 1-hour fire rated walls were found with red fire stopping mixed with a white putty, as well as areas with only white putty surrounding the penetrating conduit. The facility was unable to provide documentation confirming that the white putty used was approved for fire stopping purposes. These deficiencies were identified during a fire safety tour conducted with the Administrator and the Maintenance Director, who acknowledged the findings at the time of observation. The surveyors noted that these examples may not represent all unprotected penetrations in the facility's fire and smoke barriers, emphasizing the need for a thorough inspection of each barrier along its full length and height to ensure all penetrations are properly sealed. The report further states that every breach or penetration of a fire barrier must be appropriately repaired to restore the wall, ceiling, or floor to its original fire or smoke rated integrity. The penetrations in fire rated barriers are required to be sealed with a UL (Underwriters Laboratories) listed approved system. Photographic evidence was obtained to document the observed deficiencies.
Plan Of Correction
6/6/25 Preparation and/or execution of this plan of correction does not constitute admission or agreement of the provider of the truth of the alleged or conclusion set forth in the CMS measured star ratings. The plan of correction is prepared and executed solely because it is required by Federal and State Laws. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. No residents were affected by this alleged deficient practice. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: 2. The facility will maintain the fire/smoke barrier construction in Electrical room #5. Penetration holes five (5) through the South side; three through the North side smoke wall; thirteen (13) areas on the East and South side 1-hour fire rated walls were resealed by a 3M trained professional in accordance with NFPA 101. A thorough inspection of each fire/smoke barrier will be conducted to ensure that all penetrations are found and properly sealed in accordance with NFPA 101. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: 3. Maintenance staff re-educated on ensuring fire/smoke barrier penetrations are inspected along its full length, height and properly sealed with a UL (Underwriters Laboratories) listed approved system. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: 4. Maintenance Director or Designee will report the findings of fire/smoke barrier penetrations audits to the QAA&C monthly times three months or until substantial compliance is met. Preparation and/or execution of this plan of correction does not constitute admission or agreement of the provider of the truth of the alleged or conclusion set forth in the CMS measured star ratings. The plan of correction is prepared and executed solely because it is required by Federal and State Laws. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. No residents were affected by this alleged deficient practice. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: 2. The facility will maintain the fire/smoke barrier construction in Electrical room #5. Penetration holes five (5) through the South side; three through the North side smoke wall; thirteen (13) areas on the East and South side 1-hour fire rated walls were resealed by a 3M trained professional in accordance with NFPA 101. A thorough inspection of each fire/smoke barrier will be conducted to ensure that all penetrations are found and properly sealed in accordance with NFPA 101. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: 3. Maintenance staff re-educated on ensuring fire/smoke barrier penetrations are inspected along its full length, height and properly sealed with a UL (Underwriters Laboratories) listed approved system. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: 4. Maintenance Director or Designee will report the findings of fire/smoke barrier penetrations audits to the QAA&C monthly times three months or until substantial compliance is met.
Sprinkler System Installation Noncompliance Due to Ceiling Modification
Penalty
Summary
During an unannounced Fire & Life Safety recertification survey, it was observed that the facility failed to maintain their sprinkler system installation in accordance with NFPA 101 and NFPA 13 standards. Specifically, in Electrical Room #5, the drop ceiling had been removed, resulting in two sprinkler heads being positioned too far below the new ceiling level. This alteration led to inadequate coverage by the sprinkler system in that room, as the sprinkler heads were no longer properly aligned with the ceiling as required by code. The deficiency was identified during a facility tour conducted with the Maintenance Director, who confirmed the findings during an interview. The issue was reviewed with both the Administrator and the Maintenance Director at the exit conference, and photographic evidence was obtained to document the noncompliance. No information regarding residents or their medical conditions was included in the report, and the deficiency was limited to the physical plant and fire safety systems.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement of the provider of the truth of the alleged or conclusion set forth in the CMS measured star ratings. The plan of correction is prepared and executed solely because it is required by Federal and State Laws. K351 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. No residents were affected by this alleged deficient practice. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: 2. The facility will maintain the supervised automatic fire sprinkler system in accordance with NFPA 101. Electrical Room #5 is scheduled to be corrected on 4/15/25 to ensure adequate coverage of the automatic fire sprinkler system protection in accordance with NFPA 101. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: 3. Maintenance staff re-educated on ensuring inspection of every compartment for sprinkler system. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: 4. Maintenance Director or Designee will report the findings of the automatic fire sprinkler audits to the QAA&C monthly times three months or until substantial compliance is met.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to honor the resident representative's request to ensure that a resident received a shower on the scheduled shower days. The resident, who was admitted to the facility with severe cognitive impairment and was dependent on all care needs, had a shower schedule set for every Monday and Thursday during the 3 PM - 11 PM shift. However, documentation from the CNA task list showed that the resident received only four bed baths and three tub baths on the scheduled shower days between February 27 and March 24. An observation in the resident's room revealed a note written by the resident's sister, requesting that the resident receive a shower on her shower days. Interviews with staff confirmed the lack of shower documentation and revealed that the facility did not have a tub, which contributed to the deficiency.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute an admission or agreement of the provider of the truth of the alleged or conclusion set forth in the CMS measured star ratings. The plan of correction is prepared and executed solely because it is required by Federal and State Laws. F561 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident #71 was provided with a shower as scheduled. Staff C was re-educated to provide and document showers provided on residents' shower days and any additional days that the residents receive a shower. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: Facility audit conducted to ensure residents' showers are completed on scheduled shower days and documented appropriately. Other residents found to be affected were corrected. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: Certified Nursing Assistants (C.N.As) have been re-educated regarding Resident Rights/Right of Choices as related to receiving shower on the scheduled shower days. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: Random observation will be conducted three times per week / three months to ensure compliance. Director of Nursing/Designee will conduct weekly shower audits times four weeks and will report the findings of the audits to the QAA&C monthly times three months or until substantial compliance is met.
Inaccurate Discharge Documentation for a Resident
Penalty
Summary
The facility failed to accurately document the discharge status of a resident, identified as Resident #100, who was reviewed as part of closed records. Resident #100 was admitted with multiple diagnoses including anemia, hypertension, hip fracture, and chronic pain syndrome. The care plan for discharge indicated the resident's or responsible party's wish to return home, with a goal to safely discharge to a lower level of care once rehabilitation goals were met. On the day of discharge, progress notes documented that the resident was discharged home via private car, accompanied by two persons, with all necessary instructions and medications provided. However, the Minimum Data Set (MDS) assessment inaccurately recorded the resident's discharge status as 'Short-Term General Hospital' instead of home. This discrepancy was confirmed during an interview with the MDS Coordinator, who acknowledged the error and stated that the assessment would be updated and resubmitted. The failure to accurately document the discharge status represents a deficiency in ensuring each resident receives an accurate assessment.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident #100 assessment was corrected by the Clinical Reimbursement Director and resubmitted. No other residents were affected by the deficient practice. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: The Clinical Reimbursement Director/designee reviewed discharged residents for the last 30 days to ensure accurate documentation for discharge. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: The Clinical Reimbursement Director/designee will educate the Clinical Reimbursement staff on proper documentation and capturing discharge information accurately, including assessment of discharge destination. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: The Clinical Reimbursement Director/designee will audit discharge care plans and assessments for appropriate discharge status. Audits will be conducted weekly for four weeks, with findings reported monthly for three months at QAA&C or until substantial compliance is met.
Failure to Follow Physician Orders and Medication Management
Penalty
Summary
The facility failed to adhere to physician orders for multiple residents, leading to deficiencies in care. For one resident with severe cognitive impairment, the facility did not apply the prescribed antifungal cream as ordered. Observations revealed the resident was experiencing significant discomfort due to a rash, and interviews with staff indicated that the antifungal cream was not available due to a failure to reorder it after the stock expired. Despite the treatment administration record indicating that the cream had been administered, it was confirmed that the medication was not available, highlighting a lapse in medication management and communication among staff. Another resident, who was cognitively intact and diagnosed with hypertension, did not receive the necessary blood pressure monitoring and medication as needed. The resident's care plan required the administration of Catapres for high systolic blood pressure, but the facility did not document blood pressure readings consistently, nor did they administer the medication when required. Interviews with nursing staff revealed inconsistencies in the process of monitoring and documenting blood pressure, which contributed to the oversight in providing the necessary medication. Additionally, the facility failed to follow through with a physician's order for a urology consultation for a resident with an indwelling catheter and a diagnosis of hemorrhagic cystitis. The resident's records showed no documentation of a follow-up with urology, nor any indication that the resident refused the consultation. The Director of Nursing acknowledged the oversight, indicating a failure in ensuring that critical follow-up care was arranged and documented for the resident.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. The was obtained from the vendor and provided the unit on in the afternoon. Resident #5 was provided with the cream as ordered. The Physician for Resident #5 was notified and will continue with treatment plan. Resident #5 had physician and family notified of medication omissions and new orders received for medication administration with no negative outcomes to the patient. Nurse D, Staff F, and Unit Manager were re-educated on the process of following physician orders and timely ordering of supplies. Central Supply Clerk re-educated on timely ordering of supplies. 2. Resident #58 medication was given as ordered. Medication review completed by physician and the continued to be as needed Q 8 hours. Order provided to monitor 3 times/day and as needed. Licensed nurses re-educated on documenting the for Resident #58 every eight hours as ordered and PRN. 3. Resident #63's consultation was rescheduled from to per family request. The physician was notified of the change of the consultation date. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: A facility-wide audit was completed for current residents to identify any other residents affected by the deficient practice. No other residents were affected by the deficient practice. Current residents' Treatment Administration Records have been audited by the Director of Nursing/designee to ensure compliance with following physicians' orders. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: Licensed nurses will be re-educated on the importance of following physician orders related to Quality of Care including customer service, monitoring, and follow-up care for those residents with rashes, medication monitoring, ensuring consultations are scheduled timely. Compliance will be monitored through audits three times a week, four weeks, and weekly thereafter to ensure the practice does not recur. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: The Director of Nursing/designee will conduct treatment observations and consultation audits weekly for four weeks and then monthly for two months to ensure continued compliance. The Director of Nursing/Designee will report the findings of the audits to the QAA&C monthly times three months or until substantial compliance is met.
Inadequate Hydration Due to Mishandling of Fluid Restriction
Penalty
Summary
The facility failed to provide adequate hydration for a resident with severe cognitive impairment, as evidenced by the mishandling of her fluid restriction orders. The resident was on a 1200 milliliters per day fluid restriction, with 900 milliliters to be provided by dietary and 300 milliliters by nursing. Despite these orders, the resident reported that her fluids were frequently taken away by aides, leaving her with dry lips and a feeling of depression. During an interview, the resident expressed that her juices, which she liked to sip on throughout the day, were often discarded by staff, despite requests for them not to do so. An observation confirmed the resident's complaint, as she was seen discussing the issue with the MDS coordinator, who promised to inform the aides not to remove her juice.
Plan Of Correction
F 692 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident #16 was provided with additional fluid; no other residents were affected by the deficient practice. Resident's BIM score was redone and now 11. Psych services provided for emotional support and Licensed nurses and Certified Nursing Assistants were educated on sufficient fluid intake to maintain proper hydration and health. Additionally, not removing the fluids allowed to the residents. Care plan updated to reflect resident's preference to sip on her drink throughout the day. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: Facility audit completed for residents on fluid restrictions to ensure they are receiving adequate hydration as ordered. Director of Nursing/Designee to audit/monitor documentation weekly times four weeks. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: Assistant Director of Nursing/designee will re-educate nursing staff on the following: Ensure residents with fluid restrictions have adequate time for consumption. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: Will conduct audits weekly times four weeks. Director of Nursing /designee will report findings at monthly QAA&C monthly times three months or until substantial compliance is achieved.
Failure to Ensure Timely Physician Visits for Resident with Catheter
Penalty
Summary
The facility failed to ensure timely physician visits for a resident with a catheter. The resident, who had mild cognitive impairment and was dependent on staff for activities of daily living, was admitted to the facility and later hospitalized before being readmitted. A review of the resident's physician progress notes revealed a significant gap in physician evaluations, with no evidence of a physician visit between late August and early November. This deficiency was acknowledged by the Director of Nursing during an interview.
Plan Of Correction
F712/N55 - Physician Visits - Ensure Physicians visits in a timely manner What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. Resident #63 was seen on. The Physician assigned was re-educated on timely documentation and submission to the facility as required. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: 2. Current residents' charts have been audited over the past 30 days and timely Physician visits are in place. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: 3. Medical Records have been in-serviced on monitoring timely Physician visits. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: 4. Medical Records/designee will audit Physician's progress notes biweekly for timely visits times four weeks and report findings to QAA&C committee for three months or until substantial compliance is met.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that a resident received timely physician visits as required by 59A-4.107(6), FAC. Specifically, after being readmitted to the facility following a hospitalization, the resident's records showed a lack of physician progress notes for a period extending from the date of readmission through a subsequent period, with only one progress note documented. This gap in physician evaluation was confirmed during an interview with the DON, who acknowledged the absence of timely physician visits for the resident. The resident in question had mild cognitive impairment and was dependent on staff for activities of daily living (ADLs).
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. Resident #63 was seen on. The Physician assigned was re-educated on timely documentation and submission to the facility as required. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: 2. Current residents' charts have been audited over the past 30 days, and timely Physician visits are in place. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: 3. Medical Records have been in-serviced on monitoring timely Physician visits. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: 4. Medical Records/designee will audit Physician's progress notes biweekly for timely visits times four weeks and report findings to QAA&C committee for three months or until substantial compliance is met.
Failure to Meet Minimum CNA Staffing Requirements
Penalty
Summary
The facility failed to meet the daily average minimum staffing requirement for Certified Nurse Assistants (CNAs) during the first quarter of Fiscal Year 2025. A review of the State Minimum Nursing Staff for Long Term Care Facilities showed that on several days, the facility's daily average CNA hours fell below the required 2.0 hours per resident per day. Specifically, the daily average CNA hours recorded were 1.9411, 1.9316, 1.9837, and 1.8799 on different days within the quarter. This deficiency was confirmed during an interview with the Director of Nursing (DON), who acknowledged the findings. The report does not mention any specific residents affected or provide details about their medical history or condition at the time of the deficiency. The deficiency is classified as a Class III violation.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement of the provider of the truth of the alleged or conclusion set forth in the CMS measured star ratings. The plan of correction is prepared and executed solely because it is required by Federal and State Laws. N63- What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The staffing coordinator and Nurse Managers have been re-educated on ensuring that Certified Nursing Assistant minimum daily hour of direct care is at least 2.0 per resident per day. No residents were affected by the deficient practice. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: Audit completed for the past 30 days, and no deficient practice identified. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: Nursing Home Administrator educated the Director of Nursing and those responsible for staffing on the requirements of meeting the daily per patient day direct care hours.
Failure to Properly Post Nursing Staff Information
Penalty
Summary
The facility failed to comply with statutory requirements for daily posting of nursing staff information. During observations, the posted staff list across from the nursing station included only names, without specifying titles such as licensed nurses or certified nursing assistants (CNAs). Additionally, the posting did not indicate room assignments for the four units, making it unclear which staff members were responsible for specific residents. Surveyors had to ask staff to determine which personnel were assigned to particular residents, and random residents questioned were unable to identify their assigned nurse by looking at the posted information. The Assistant Director of Nursing confirmed these findings during an interview.
Plan Of Correction
The Nursing Home Administrator, Director of Nursing, and Staffing Coordinator during staffing meetings will continue to ensure compliance with the requirement. On weekends, the Director of Nursing will verify with the Supervisor and monitor callouts for replacements. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee will review findings weekly times four weeks and report compliance during the monthly QA&A Committee monthly times three months or until substantial compliance is met. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The missing staffing information such as titles and room assignments for the Certified Nursing Assistants and Licensed Nurses identified were corrected. No residents were affected by the deficient practice. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: Meeting scheduled with the resident council on to review the posted assignments to ensure understanding. Random residents will be questioned on who their assigned nurses and the Certified Nursing Assistants are to ensure understanding. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: Nurse Managers and Licensed Nurses have been re-educated regarding posting nurse staffing information to include titles and room assignments. Weekly audits will be completed to ensure compliance times four weeks. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee will review findings weekly times four weeks and report compliance during the monthly QA&A Committee monthly times three months or until substantial compliance is met.
Failure to Provide Scheduled Showers per Resident Representative's Request
Penalty
Summary
The facility failed to honor a resident representative's request to ensure that a resident received showers on their scheduled shower days. The resident, who was dependent for all care needs as indicated by a Minimum Data Set (MDS) assessment score of 3, had a posted note from her sister on the bulletin board requesting that she receive showers on her scheduled days. The resident's care plan included showers every Monday and Thursday during the 3 PM-11 PM shift. Record review showed that, instead of showers, the resident received four bed baths and three tub baths on the scheduled shower days. Staff interviews confirmed that a bed bath was provided instead of a shower, and the Director of Nursing verified the lack of shower documentation on the CNA task list. It was also confirmed that the facility does not have a tub, further indicating that the resident did not receive showers as scheduled.
Plan Of Correction
N 181 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident #71 was provided with a shower as scheduled. Staff C was re-educated to provide and document showers provided on residents' shower days and any additional days that the residents receive a shower. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: Facility audit conducted to ensure residents' showers are completed on scheduled shower days and documented appropriately. Other residents found to be affected were corrected. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: Certified Nursing Assistants (C.N.As) have been re-educated regarding Resident Rights/Right of Choices as related to receiving shower on the scheduled shower days. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: Random observation will be conducted three times per week/three months to ensure compliance. Director of Nursing/Designee will conduct weekly shower audits times four weeks and will report the findings of the audits to the QAA&C monthly times three months or until substantial compliance is met.
Failure to Provide Adequate Hydration, Medication Administration, and Physician-Ordered Consultations
Penalty
Summary
The facility failed to provide adequate and appropriate health care to several residents as evidenced by multiple deficiencies. One resident on a 1200 mL per day fluid restriction, with specific allocations for dietary and nursing staff, was not able to access the fluids she was allowed. The resident reported that staff repeatedly removed her juice before she could finish it, despite her requests to leave it for her to sip throughout the day. Observations confirmed the resident's complaints, and staff acknowledged the issue but only offered to replace the juice after it was taken away. Another resident with a severe cognitive impairment had a physician's order for a specific cream to be applied to affected skin areas during the day and evening shifts. Despite this order, the cream was not available for use, as the supply had run out and expired stock had been discarded without timely reordering. Staff interviews revealed that the cream had been unavailable for several days, and the Treatment Administration Record showed that nurses had signed off on the administration of the cream even though it was not actually provided. The resident was observed scratching her arms and had visible skin issues, indicating the treatment was not being administered as ordered. A third resident with a history of hypertension had physician orders for routine and as-needed antihypertensive medications, with instructions to administer the as-needed medication for blood pressure readings above a certain threshold. However, staff were not consistently monitoring or documenting the resident's blood pressure every eight hours as required, resulting in missed opportunities to administer the as-needed medication when indicated. Interviews with nursing staff revealed inconsistent practices in monitoring and documentation, and review of records confirmed that blood pressure readings were not taken or recorded as frequently as ordered. Additionally, another resident did not receive a required follow-up consultation as ordered by the physician, with no documentation of refusal or completion.
Plan Of Correction
1. Resident #16 was provided with additional fluid; no other residents were affected by the deficient practice. Resident's BIM score was redone and now 11. Psych services provided for emotional support and Licensed nurses and Certified Nursing Assistants were educated on sufficient fluid intake to maintain proper hydration and health. Additionally, not removing the fluids allowed to the residents. Care plan updated to reflect resident's preference to sip on her drink throughout the day. Facility audit completed for residents on fluid restrictions to ensure they are receiving adequate hydration as ordered. Director of Nursing/Designee to audit/monitor documentation weekly times four weeks. Assistant Director of Nursing/designee will re-educate nursing staff on the following: Ensure residents with fluid restrictions have adequate time for consumption. Will conduct audits weekly times four weeks. Director of Nursing/designee will report findings at monthly QAA&C meetings monthly times three months or until substantial compliance is achieved. 2. The was obtained from the vendor and provided the unit on in the afternoon. Resident #5 was provided with the cream as ordered. The Physician for Resident #5 was notified and will continue with treatment plan. Resident #5 had physician and family notified of medication omissions and new orders received for medication administration with no negative outcomes to the patient. Nurse D, Staff F, and Unit Manager were re-educated on the process of following physician orders and timely ordering of supplies. Central Supply Clerk re-educated on timely ordering of supplies. 3. Resident #58 medication was given as ordered. Medication review completed by physician and the continued to be as needed Q 8 hours. Order provided to monitor three times/day and as needed. Licensed nurses were re-educated on documenting the for Resident #58 every eight hours as ordered and PRN. 4. Resident #63's consultation was rescheduled from to per family request. The physician was notified of the change of the consultation date. A facility-wide audit was completed for current residents to identify any other residents affected by the deficient practice. No other residents were affected by the deficient practice. Current residents' Treatment Administration Records have been audited by the Director of Nursing/designee to ensure compliance with following physicians' orders. Licensed nurses will be re-educated on the importance of following physician orders related to Quality of Care including customer service, monitoring, and follow-up care for those residents with rashes, medication monitoring, and ensuring consultations are scheduled timely. Compliance will be monitored through audits three times a week, four weeks, and weekly thereafter to ensure the practice does not recur. The Director of Nursing/designee will conduct treatment observations and consultation audits weekly for four weeks and then monthly for two months to ensure continued compliance. The Director of Nursing/Designee will report the findings of the audits to the QAA&C monthly times three months or until substantial compliance is met.
Inaccurate Documentation of Resident Discharge Status
Penalty
Summary
The facility failed to accurately document the discharge status of a resident, as required by 59A-4.109(1), FAC, which mandates a comprehensive and accurate assessment of each resident's functional capacity and discharge status. The resident in question was admitted with diagnoses including wasting and atrophy, abnormalities of gait and mobility, and was documented in the care plan as wishing to return home. The care plan goal was to safely discharge the resident to a lower level of care, such as home, when rehabilitation goals were met. Progress notes and social services documentation confirmed that the resident was discharged home, with details indicating the resident left the facility via private car, accompanied by two persons, and received food and medication as ordered prior to departure. The resident was alert, oriented, and independent in decision-making, and had requested to be discharged home to coincide with the discharge of a spouse from the hospital. Durable medical equipment was ordered for the resident prior to discharge. Despite this, the Minimum Data Set (MDS) discharge assessment inaccurately recorded the resident's discharge status as 'Short-Term General Hospital' instead of home. During an interview, the MDS Coordinator confirmed the resident was discharged home and acknowledged the error in the MDS assessment, stating that it would be updated and resubmitted.
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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.
Trusted data from CMS and state health departments
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