Royal Care Of Avon Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Avon Park, Florida.
- Location
- 1213 W Stratford Rd, Avon Park, Florida 33825
- CMS Provider Number
- 105812
- Inspections on file
- 19
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Royal Care Of Avon Park during CMS and state inspections, most recent first.
Two residents with known behavioral conflict and one with dementia and mood instability engaged in a verbal altercation in a common area that escalated when one resident kicked the other, causing a fall and shoulder injury, while no staff were present to intervene. Staff had prior knowledge of the aggressive resident’s history of verbal and physical behaviors and the pair’s past roommate conflicts, and behavior monitoring for psychotropic use lacked specific behavior descriptions. The DON later confirmed that key staff statements were not obtained and that staff could not clearly describe the behaviors previously documented, demonstrating a failure to provide adequate supervision and behavior-specific monitoring to prevent resident-to-resident abuse.
A resident developed a Stage 4 pressure ulcer due to the facility's failure to identify and treat a new area of skin impairment. The resident did not receive adequate preventive measures or timely treatment, resulting in an infected ulcer that required hospitalization and a wound vac.
The facility failed to maintain a clean and homelike environment, with surveyors detecting offensive odors in the front lobby, nurses' station, and four resident rooms over several days. The Environmental Services Director acknowledged that their audit process does not include checking for odors, and despite using an IT ticket system for reporting concerns, the issue persisted.
The facility failed to ensure accurate PASARR screenings for multiple residents, missing key diagnoses that could have warranted Level II reviews. Interviews revealed that the process for reviewing and correcting PASARRs was not adequately followed.
The facility failed to provide proper wound care for four residents and did not obtain physician's orders for hand splints for one resident. Observations revealed undated and soiled dressings, improper sterile techniques, and lack of documentation for wound care and refusals, leading to deficiencies in care.
The facility failed to ensure proper storage of drugs and biologicals, with treatment carts left unlocked and a bottle of nasal spray found on a resident's bedside dresser. Staff acknowledged the oversights and secured the carts after being made aware.
The facility failed to maintain food safety standards, including unclean kitchen areas, improper food storage, and inadequate equipment maintenance. Black soil was found on the floors of the walk-in refrigerator and freezer, expired egg salad was stored, and a black substance resembling biogrowth was noted on a wall. Additionally, frozen ground beef was improperly thawed, and a spatula with burnt edges and broken thermometer were found. These deficiencies were confirmed by the facility's dietitian and dietary director.
The facility failed to maintain an effective infection control program, with staff not donning appropriate PPE, not assisting residents with hand hygiene before meals, and not maintaining urinary catheters in a sanitary manner. Additionally, inconsistencies in cleaning medical equipment were observed.
The facility failed to securely affix handrails in the corridors of the West and South units. During tours, multiple handrails were found to be loose and not firmly secured to the wall. Staff and the Director of Environmental Services acknowledged the issue, but discrepancies were found in the inspection process.
The facility failed to maintain dignity and a homelike dining experience for residents in the West dining/common area. Observations revealed that staff did not remove dinnerware from trays when serving residents, and plate covers remained on the tables while residents dined. Interviews indicated a lack of awareness or adherence to the facility's policy on dignity.
A resident with broken, chipped teeth and dental caries was inaccurately documented as having normal dentition in multiple assessments. Despite visible dental issues, no care plan or dental consults were provided, and the resident's medical records consistently marked her dental status as normal.
A resident with Parkinson's Disease and an infection due to an internal knee prosthesis did not receive proper IV medication administration. The IV tubing was not labeled, and a significant amount of vancomycin remained in the bag. Staff could not explain the oversight, and the DON confirmed it was a medication error.
The facility failed to ensure proper respiratory care for residents, including improper storage of equipment, lack of physician's orders, failure to change oxygen tubing weekly, and missing cautionary signage. Staff interviews and observations confirmed these deficiencies.
The facility failed to post complete daily nursing staff information. Observations on 5/9/24 revealed missing details for the 7 p.m. to 7 a.m. shift and the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts. A review of the 5/8/24 posting also showed missing CNA and PCA information for the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts.
The facility failed to administer antihypertensive medications according to prescribed parameters for a resident with multiple diagnoses, including Type 2 Diabetes Mellitus and essential hypertension. The medications Losartan, Diltiazem, and Spironolactone were given outside of the specified blood pressure limits, as confirmed by the DON.
The facility failed to maintain a medication error rate below 5%, resulting in a 21.43% error rate. An RN crushed extended-release medications and administered them incorrectly to a resident, and administered medications late to another resident. The DON confirmed the errors and policy violations.
A resident with Parkinson's Disease and an infection due to an internal knee prosthesis did not receive the full dose of prescribed vancomycin intravenously. The IV tubing was not labeled, and a significant amount of medication remained in the bag. Staff and the DON confirmed this as a medication error, and the facility's policy was not followed.
A resident with several broken, chipped teeth, and dental caries was not assisted in obtaining routine dental care. Despite being cognitively intact and having obvious dental issues, the resident's MDS assessments did not reflect any dental problems, and there was no care plan addressing the dental status. Interviews revealed that the facility's protocol for dental referrals was not followed, leading to the deficiency.
Failure to Supervise Leading to Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent resident-to-resident abuse, resulting in a physical altercation between two residents. Resident #2, who was cognitively intact with a BIMS score of 15 and had diagnoses including abnormalities of gait and mobility, muscle weakness, and type 2 diabetes, alleged that another resident kicked her, causing a fall and subsequent left shoulder pain. Resident #3, who had severe cognitive impairment with a BIMS score of 6 and diagnoses including unspecified mood disorder, depression, and dementia, had a documented history of verbally and physically threatening staff and other residents, aggressive behavior, and pilfering items. The facility’s care plan for Resident #3 identified behavioral symptoms and cognitive loss/dementia, with approaches including redirection, diversional activities, and, later, 1:1 sitter supervision. Prior to the incident, staff were aware that Resident #3 exhibited verbal aggression and had prior altercations with other residents to the point of needing separation, and that the two involved residents had previously been roommates who did not get along, leading to a room change. Resident #3 was also on Depakote for mood instability, mood swings, and aggression, with behavior monitoring ordered. However, the behavior monitoring documentation for January showed only intervention codes (e.g., giving food, fluids, encouraging rest) without any description of the specific behaviors exhibited, and facility staff, including the MDS coordinators, could not state what behaviors had occurred on those dates despite acknowledging that some type of behavior must have been present. The facility’s abuse policy required identification of residents with behaviors that might lead to conflict, sufficient supervision, and monitoring for changes that could trigger abusive behavior, but the documentation and staff interviews did not demonstrate clear, behavior-specific monitoring or consistent preventive supervision. On the day of the event, the altercation occurred in the east wing atrium/common area near the nurses’ station. Resident #8, another resident, reported witnessing Resident #3 approach Resident #2 in a wheelchair, exchange derogatory names, stand up from their wheelchairs, and then kick Resident #2 in the shin, causing Resident #2 to fall to her left side. Resident #8 stated no staff were present at the time. Staff B, an RN, reported hearing Resident #2 crying and asking for help, then seeing her in her wheelchair and separating the residents, but did not witness the actual kick or fall. The DON’s investigation notes, based on interviews, indicated that Resident #3 admitted to pushing another resident after a verbal altercation, and that Resident #2 and Resident #8 both described Resident #3 kicking Resident #2 and causing her to fall. The facility’s abuse policy required sufficient staffing, supervision, and obtaining signed witness statements, but the DON confirmed that written, signed staff statements were not obtained from key staff present that shift, and staff could not clearly account for supervision at the time of the incident, supporting the finding that the facility failed to provide adequate supervision to prevent resident-to-resident abuse.
Failure to Prevent and Treat Pressure Ulcer
Penalty
Summary
The facility failed to identify and treat a new area of skin impairment for a resident, which resulted in the development of an advanced stage pressure ulcer. The resident, who had multiple health conditions including Type 2 Diabetes Mellitus, muscle weakness, and spinal stenosis, initially had no pressure ulcers upon admission. However, the resident developed an unstageable pressure ulcer on the sacral region, which later progressed to a Stage 4 pressure ulcer. The resident reported that the facility did not provide adequate treatment or preventive measures, such as a special mattress, until the ulcer had significantly worsened and become infected, necessitating hospitalization and the use of a wound vac for treatment. Observations and interviews revealed that the resident was often positioned on his back and did not receive consistent repositioning or the use of heel protectors as outlined in his care plan. The facility's documentation showed gaps in progress notes and skin assessments, with no records indicating the development of the pressure ulcer at a lower stage. The facility's Director of Nursing and Medical Director provided conflicting information about the resident's care and the timeline of the pressure ulcer's development. The Medical Director initially claimed the ulcer was unavoidable due to the resident's debility but later admitted to not being familiar with the resident's case. The facility's policy on pressure ulcer prevention and treatment was not adequately followed, as evidenced by the lack of timely assessments, appropriate interventions, and consistent documentation. The resident's care plan included measures such as turning and repositioning every two hours, using an air mattress, and reporting changes in skin condition to the primary care physician. However, these interventions were not consistently implemented, leading to the resident's pressure ulcer progressing to an advanced stage and causing significant harm.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment, as evidenced by the presence of offensive odors in multiple areas. Upon entering the facility, the survey team detected a smell of old urine in the front lobby. Similar odors were noted in front of the nurses' station and in four resident rooms over the course of several days. Specifically, rooms 103, 107, 109, and 110 were identified as having strong and offensive odors, some of which were not related to urine. These observations were made at various times, indicating a persistent issue with maintaining a clean environment. An interview with the Environmental Services Director revealed that the facility's current audit process does not include checking for offensive odors. The Director mentioned that if an odor is noticed, a deep clean is performed, and that room 110B had recently undergone such a cleaning, including a bed replacement. The facility uses an IT ticket system for reporting environmental concerns, which are then prioritized and addressed by the Environmental Services team. Despite these measures, the persistent odors suggest that the current processes are insufficient to maintain a consistently clean and homelike environment for residents.
Inaccurate PASARR Screenings for Multiple Residents
Penalty
Summary
The facility failed to ensure the Level I Preadmission Screening and Resident Review (PASARR) was accurate for four residents. Resident #15 was admitted with diagnoses including vascular dementia, bipolar disorder, and major depressive disorder, but the PASARR did not reflect these diagnoses, and no Level II PASARR was required. Similarly, Resident #26's PASARR did not include a diagnosis of bipolar disorder, and Resident #28's PASARR missed several qualifying diagnoses such as anxiety, schizoaffective disorder, and PTSD. These inaccuracies were not corrected at the time of admission, which could have warranted a Level II PASARR review. Additionally, Resident #38's PASARR was not updated to reflect a new diagnosis of schizoaffective disorder, which was added after the initial screening. This oversight meant that a Level II PASARR review was not conducted when it should have been. Interviews with the Director of Nursing and the Social Services Director revealed that the facility's process for reviewing and correcting PASARRs was not adequately followed, leading to these deficiencies.
Failure to Provide Proper Wound Care and Follow Physician's Orders
Penalty
Summary
The facility failed to provide wound care and treatment in accordance with professional standards of practice for four residents and did not ensure physician's orders were obtained for the application of splints for one resident. Resident #67 had a wound infection on his right knee that required dressing changes. However, the wound dressing was observed without a documented date, and the facility did not follow the physician's orders for wound care. Resident #328 had a wound on his right middle finger that was supposed to be dressed daily, but the dressing was not applied, and there was no documentation of the resident refusing treatment or removing the dressing himself. The facility's staff failed to document the wound care treatment and any refusals properly, as per the facility's policy. Resident #36 was observed with a soiled and undated dressing on his right shin, which was not changed as per the treatment administration record. The resident had a skin tear that required dressing changes every other day, but the facility did not follow the prescribed wound care protocol. Resident #177 had bilateral below-knee amputations with sutures/staples in the surgical sites. The wound dressing changes were not performed using proper sterile techniques, as the nurse used bare hands to handle gauze and did not clean the scissors between cutting the old and new dressings. This practice was against the facility's policy for dry/clean dressings. Resident #41 was observed wearing bilateral hand splints without a physician's order. The resident's care plan did not include the use of hand splints, and the occupational therapist confirmed that the splints were not part of the care plan. The facility's policy required that care plans be individualized and include all necessary interventions, but this was not done for Resident #41. The lack of proper documentation and adherence to physician's orders and facility policies led to deficiencies in the care provided to these residents.
Improper Storage of Drugs and Biologicals
Penalty
Summary
The facility failed to ensure proper storage of drugs and biologicals, as evidenced by two specific incidents. On two separate days, a treatment cart was observed unlocked and unattended in the South unit hallway. On the first occasion, a Registered Nurse (RN) admitted to leaving the cart unlocked after receiving items from the pharmacy. On the second occasion, the facility's Infection Preventionist (IP) and Assistant Director of Nursing (ADON) did not notice the unlocked cart and walked away without securing it. Both instances were acknowledged by the staff involved, who subsequently locked the cart after being made aware of the oversight. Additionally, during a medication administration observation, a bottle of nasal spray was found on a resident's bedside dresser. The RN administering the medication was unaware of how the nasal spray got there and speculated it might have been placed by a family member. The Director of Nursing (DON) later confirmed that no residents were allowed to self-administer medications and that all medications should be stored in the facility's medication carts. The facility's policy mandates that all drugs and biologicals be stored securely and that medication carts be locked when not in use.
Failure to Maintain Food Safety Standards
Penalty
Summary
The facility failed to maintain food safety standards, which included maintaining clean floors and walls, properly storing ready-to-eat refrigerated Time/Temperature Control for Safety (TCS) food, thawing frozen TCS food correctly, and keeping equipment in good condition. During an initial tour of the kitchen, black soil was observed on the floors of the walk-in refrigerator and freezer. A container of egg salad with an expired use-by date was found in the reach-in refrigerator, and a black substance resembling biogrowth was noted on a wall in the dry storage area. Additionally, a 10-pound log of frozen ground beef was improperly thawed in a prep sink without running water, and a spatula with burnt edges was found hanging above the sink. The same spatula was observed again during a follow-up visit, along with three scoops with rough, uncleanable plastic handles. A broken thermometer was also found in a resident nourishment mini refrigerator. These observations were confirmed through interviews with the facility's dietitian and dietary director, who provided documentation of previous training and performance improvement plans that did not address the identified concerns during the survey. The facility's policies on sanitization and food storage were not adhered to, as evidenced by the unclean kitchen areas and improper food handling practices. The kitchen weekly cleaning schedule indicated that specific staff members were responsible for cleaning the walk-in refrigerator, freezer, and storage room, but these tasks were not adequately performed. The facility's dietitian and dietary director acknowledged the deficiencies and provided documentation of employee training and performance improvement plans, but these measures were insufficient to prevent the identified issues. The failure to maintain food safety standards has the potential to cause foodborne illness for the majority of the facility's residents.
Infection Control Deficiencies
Penalty
Summary
The facility failed to develop and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. Staff members did not don appropriate personal protective equipment (PPE) before entering the rooms of residents under transmission-based precautions for COVID-19. Specifically, staff were observed entering rooms without eye protection, and some staff donned N95 masks over surgical masks, which compromised the fit and effectiveness of the N95 masks. Additionally, staff did not doff PPE before exiting the rooms, further risking the spread of infection. Interviews with staff revealed a lack of awareness and understanding of the proper PPE protocols, and the facility's Infection Preventionist and Director of Nursing confirmed that the observed practices were not in line with the facility's policies or infection control guidelines. The facility also failed to ensure proper hand hygiene practices for residents before meals. During meal service observations, residents were not assisted with hand hygiene, which is a critical step in preventing the spread of infections. This lapse in protocol was confirmed by the Director of Nursing during an interview. Additionally, the facility did not maintain urinary catheters in a sanitary manner. Observations showed catheter tubing lying on the floor, which poses a significant risk for infection. The care plan for the resident with the urinary catheter explicitly stated that the drainage bag should be kept below the waist and off the floor, but this was not adhered to. Further deficiencies were noted in the cleaning and disinfection of medical equipment. During a medication administration observation, a registered nurse did not clean the stethoscope used for blood pressure measurement, although other equipment was disinfected. This inconsistency in following infection control protocols highlights a broader issue within the facility's infection prevention and control program. The facility's policies, last revised in January 2021, were not being effectively implemented or followed by the staff, leading to multiple instances of non-compliance and increased risk of infection spread among residents and staff.
Failure to Securely Affix Handrails in Corridors
Penalty
Summary
The facility failed to equip corridors with securely affixed handrails on two of its three units, specifically the West and South units. During a tour on the [NAME] unit, a handrail between rooms was observed to be loose and not firmly secured to the wall. Similarly, on the South unit, multiple handrails between rooms were found to be loose and not securely affixed. Staff I, an LPN on the South unit, acknowledged the issue but admitted she had not noticed the loose handrails prior to the survey. The Director of Environmental Services (DES) also confirmed the handrails were loose and stated that inspections are conducted weekly, and maintenance concerns can be documented in the electronic maintenance system. However, the Weekly Hand Rail Checks for the [NAME] unit showed no issues, indicating a discrepancy in the inspection process. The facility's policy on maintenance service, last revised in December 2009, mandates that the maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. This includes maintaining the building in compliance with federal, state, and local laws, and ensuring the building is free from hazards. Despite this policy, the observations during the tours and the interviews with staff revealed that the handrails were not maintained in a safe condition, leading to the identified deficiency.
Failure to Maintain Dignity and Homelike Dining Experience
Penalty
Summary
The facility failed to maintain dignity and a homelike dining experience for residents in the West dining/common area. Observations on multiple occasions revealed that staff did not remove dinnerware from trays when serving residents. Specifically, during the noon meal service, several residents were served their meals with dinnerware left on the trays, and plate covers remained on the tables while residents dined. This practice was observed with four out of five residents sitting at the dining tables. Additionally, the Director of Nursing (DON) was seen standing over a resident and cutting up food with the dinnerware still on the serving tray. Interviews with staff, including the Assistant Director of Nursing/Risk Manager (ADON/RM) and the Dietary Director, indicated a lack of awareness or adherence to the facility's policy regarding the removal of dinnerware from trays. The DON confirmed that plates should be removed from trays, but the facility's policy was not readily available. The facility's policy on dignity, revised in August 2009, emphasized treating residents with dignity and respect, which includes assisting them in maintaining and enhancing their self-esteem and self-worth. However, the observed practices did not align with this policy, leading to the deficiency.
Inaccurate Dental Status Documentation
Penalty
Summary
The facility failed to accurately reflect a resident's dental status, as observed during multiple instances. Resident #17 was noted to have several broken, chipped teeth, dental caries, and black gums around several teeth. Despite these observations, the resident's Annual Minimum Data Set (MDS) assessments did not document any dental issues, and the resident did not have a care plan addressing her dental status. The resident's weight had gradually decreased over several months, but her meal intake remained high, averaging 76 to 100% in April 2024. The resident's medical records, including social history assessments, speech therapy screens, and nutritional evaluations, consistently marked her dental status as normal, with no referrals necessary for dental issues. Progress notes from healthcare providers also documented normal dentition, with no indication of dental consults or services provided to the resident. The Director of Nursing was informed of the inaccuracies in the resident's MDSs regarding her oral/dental status.
Failure to Properly Administer IV Medication
Penalty
Summary
The facility failed to provide proper administration of intravenous (IV) medication in accordance with professional standards of practice for a resident diagnosed with Parkinson's Disease and an infection due to an internal left knee prosthesis. The resident had a physician's order for vancomycin to be administered intravenously every other day. During an observation, it was noted that the IV tubing was not labeled with the date it was hung, and a significant amount of the medication remained in the IV bag, indicating that the medication was not fully administered. Staff members, including a Registered Nurse (RN) and a Licensed Practical Nurse (LPN), were unable to explain why the IV tubing was not labeled or why the medication was not fully administered. Further interviews with the Unit Manager (UM) and the Director of Nursing (DON) confirmed that the IV tubing and medication should have been labeled with the date and that the medication should have been fully administered. The DON stated that the medication should run via an IV pump or a manual flow regulator until fully administered and that failure to do so would be considered a medication error. Photographic evidence supported these findings, and the staff acknowledged the oversight but could not provide a reason for the lapse in proper procedure.
Failure to Ensure Proper Respiratory Care
Penalty
Summary
The facility failed to ensure proper respiratory care for residents, specifically in the areas of equipment storage, obtaining physician's orders, changing oxygen tubing, and posting necessary signage. Resident #54 was observed with an oxygen concentrator and nasal cannula tubing that was not dated or stored in a plastic bag as required. Additionally, there was no physician's order for oxygen therapy for Resident #54 prior to 5/9/2024, despite the resident using oxygen on an as-needed basis. Interviews with staff confirmed that the equipment should have been labeled and stored properly, and a physician's order should have been in place before administering oxygen. Resident #126's oxygen tubing was not changed weekly as per physician's orders, with the tubing dated 4/21/24 still in use on 5/7/24. Furthermore, there were no cautionary and safety signs indicating the use of oxygen posted outside Resident #126's room. The resident's medical records and care plan indicated a need for oxygen therapy due to conditions such as COPD and recent respiratory failure. Interviews with staff and the DON confirmed that the oxygen tubing should be changed weekly and that appropriate signage should be posted. The facility's policies on oxygen administration and storage of respiratory equipment were not followed, leading to these deficiencies. The policies required a physician's order for oxygen administration, proper storage of respiratory equipment in plastic bags, and weekly changes of oxygen tubing. The lack of adherence to these policies was confirmed through staff interviews and observations, highlighting a failure to provide respiratory care in accordance with professional standards.
Incomplete Daily Nursing Staff Information
Penalty
Summary
The facility failed to post daily nursing staff information accurately, as required. On 5/9/24 at 8:13 a.m., the posted staffing information in the front lobby was observed to be incomplete. The posting, dated 5/9/24, indicated a census of 79 residents and listed the staffing for the 7 a.m. to 7 p.m. shift, including 3 Registered Nurses (RN) and 5 Licensed Practical Nurses (LPN), and for the 7 a.m. to 3 p.m. shift, including 9 Certified Nursing Assistants (CNA) and 1 Patient Care Assistant (PCA). However, it did not include the number of licensed staff scheduled for the 7 p.m. to 7 a.m. shift or the number of CNAs or PCAs scheduled for the 3 p.m. to 11 p.m. or 11 p.m. to 7 a.m. shifts. Additionally, a review of the daily staffing information dated 5/8/24 showed no CNA or PCA information for the 3 p.m. to 11 p.m. or 11 p.m. to 7 a.m. shifts.
Failure to Administer Antihypertensive Medications per Parameters
Penalty
Summary
The facility failed to provide medications appropriately for one resident out of five sampled, specifically related to antihypertensive medications. The resident, who had diagnoses including Type 2 Diabetes Mellitus with hyperglycemia, unspecified cirrhosis of the liver non-alcoholic, and essential hypertension, was administered Losartan, Diltiazem, and Spironolactone outside of the prescribed parameters. For instance, Losartan was given on two occasions despite the resident's systolic blood pressure being below the threshold. Similarly, Diltiazem was administered when the resident's blood pressure was below the set limit, and Spironolactone was inconsistently administered. The Director of Nursing confirmed that the medications were not administered according to the specified parameters, acknowledging the discrepancy during an interview.
Medication Administration Errors and Policy Violations
Penalty
Summary
The facility failed to ensure that the medication error rate was less than 5.00%, resulting in a 21.43% medication error rate. During an observation of medication administration, a registered nurse (RN) administered medications to a resident by crushing extended-release medications, which were listed on the facility's 'DO NOT CRUSH' list. The medications included Metoprolol Succinate Extended-Release and Oxybutynin Extended-Release. Additionally, the RN dispensed a Multi-Vitamin tablet that did not contain minerals, contrary to the resident's Medication Administration Record (MAR). The Director of Nursing (DON) confirmed that these medications should not have been crushed and that the Multi-Vitamin tablet was incorrect. The resident's blood pressure and pulse were also not within the parameters specified for administering Metoprolol Succinate Extended-Release, yet the medication was still given. This incident highlights a significant deviation from the facility's medication administration policies and procedures, which require medications to be administered as prescribed and within pharmacy guidelines. In another instance, the same RN administered medications to a second resident, including Senna, Aspirin, Metformin, and Humulin R. The medications were administered significantly later than the scheduled times, with the Aspirin and Senna given approximately one and a half hours late and the Metformin administered two and a half hours late. The RN also crushed the medications and mixed them with applesauce before administration, despite the resident being able to take the medications whole. The DON was informed of the lateness of the medication administration. The facility's policies on administering oral medications and ensuring timely administration were not followed, leading to these medication errors.
Failure to Ensure Resident is Free from Significant Medication Errors
Penalty
Summary
The facility failed to ensure that a resident receiving intravenous medication was free from significant medication errors. Resident #54, who was admitted with diagnoses of Parkinson's Disease and an infection due to an internal left knee prosthesis, had a physician's order for vancomycin to be administered intravenously. During an observation, it was noted that the IV tubing was not labeled with the date it was hung, and a significant amount of the medication remained in the IV bag. Staff H, a Registered Nurse and Unit Manager, was unable to explain why the medication was not fully administered or why the IV tubing was not labeled. Photographic evidence was obtained to document the observation. Further interviews with Staff G, another Registered Nurse and Unit Manager, and the Director of Nursing (DON) confirmed that the medication should have been fully administered and the IV tubing should have been labeled. The facility's policy on medication errors defines significant errors as wrong dose or omission, and the failure to fully administer the vancomycin to Resident #54 was acknowledged as a medication error. The progress notes did not document the amount of medication left in the bag, further indicating a lapse in proper medication administration procedures.
Failure to Assist Resident in Obtaining Routine Dental Care
Penalty
Summary
The facility failed to assist a resident in obtaining routine dental care, as evidenced by the condition of the resident's teeth and gums. The resident, who was cognitively intact according to the most recent Annual Minimum Data Set (MDS), was observed with several broken, chipped teeth, and dental caries. Despite these obvious dental issues, the resident's MDS assessments did not reflect any dental problems, and there was no care plan addressing the resident's dental status. The resident had a small gradual weight loss over several months, but her meal intake remained high, averaging 76 to 100% in April 2024. The resident's medical record did not document any referrals for dental consults or services, despite the facility having a dental service that visited monthly. Interviews with the Social Services Director and the Director of Nursing revealed that the facility's protocol for referring residents to dental services involved staff notifying the social worker if a dental problem was observed. However, in this case, the resident's dental issues were not identified or referred for a dental consult. The Social Services Director confirmed that the resident had not been referred to the dentist, and the Director of Nursing could not specify how often the contract dental service visited the facility. The lack of documentation and referral for dental care led to the deficiency identified in the report.
Latest citations in Florida
Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
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