Sarasota Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sarasota, Florida.
- Location
- 1524 East Avenue South, Sarasota, Florida 34239
- CMS Provider Number
- 105155
- Inspections on file
- 20
- Latest survey
- November 12, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Sarasota Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was readmitted after hospital treatment for scabies, but the facility did not document required skin assessments for the resident, close contacts, or staff, nor did it clean or launder clothing, bedding, or the room as per policy. No staff in-services on scabies were conducted, resulting in noncompliance with infection control protocols.
A resident with severe cognitive impairment and physical dependency was found with a significant bruise and later diagnosed with a femoral neck fracture. The facility did not document a thorough investigation, as required by policy, with missing staff statements and unwitnessed accounts of the incident. Interviews revealed that the DON and other staff could not provide written documentation or clear details about how the injury occurred.
The facility did not have effective supervision processes for cognitively impaired residents with aggressive behaviors, resulting in multiple incidents where residents physically assaulted each other, causing injuries such as scratches and skin tears. Staff were not present or did not intervene during these altercations, and existing monitoring programs were insufficient to prevent these events.
Multiple residents with cognitive impairment and aggressive behaviors were involved in repeated physical altercations, including hitting and scratching, resulting in injuries. These incidents occurred in various areas of the secured dementia unit without adequate staff supervision or individualized care plan interventions. Staff were often unaware of residents' whereabouts, and behavioral monitoring was insufficient, leading to a pattern of harm and risk among residents.
A facility failed to ensure a dietary aide was screened for a history of abuse, neglect, or exploitation before employment. Despite a policy requiring background checks, the aide was not entered into the Florida Agency For Healthcare Administration's Care Provider Background Screening Clearinghouse, and a new screening was not obtained after a break in employment. The aide worked several days without the required screening, violating state regulations and facility policies.
A resident with severe cognitive impairment was administered psychotropic medications without informed consent from the appointed health care surrogate (HCS). The facility failed to inform the HCS about the risks, benefits, side effects, and alternatives of the medications. Interviews and record reviews confirmed the absence of signed consent forms and documentation of discussions with the HCS.
A resident with severe cognitive impairment and multiple medical conditions experienced an injury of unknown origin. The facility failed to thoroughly investigate the incident, as the investigation did not consider the possibility that the right arm fracture occurred when a left arm injury was documented. The investigation lacked staff statements and an interview with the LPN who noted the initial injury. The facility's failure to conduct a thorough investigation was acknowledged by the current Administrator and Interim DON.
A facility failed to provide adequate social services for a resident with toxic encephalopathy and dementia, who wished to relocate closer to family. Despite the family's request for assistance, the social worker did not actively help in finding a suitable facility, leaving the family to independently search for a specialized dementia care unit. The Nursing Home Administrator acknowledged that the social services director should assist in such situations.
A facility failed to maintain proper communication and documentation for a resident receiving dialysis. The required Dialysis Communication Tool forms were missing or incomplete for several dates, lacking necessary information, signatures, and timestamps. This deficiency was confirmed by staff, highlighting a failure to adhere to the facility's policy, which could impact the resident's care and safety.
The facility failed to provide necessary dental services for four residents, resulting in unmet dental needs. A resident was edentulous and had not received dentures or seen a dentist since admission. Another resident had multiple missing and broken teeth but did not receive dental care. A third resident had broken teeth, and their care plan did not address the issue. Lastly, a resident with loose dentures experienced weight loss, and the facility staff were unaware of the problem.
A facility licensed for 169 beds failed to ensure their full-time social worker met the required qualifications. The current social worker, who started in March 2024, only held a bachelor's degree in social work and lacked the necessary one year of supervised experience in a healthcare setting. Additionally, there was no signed job description on file. The Regional Consultant confirmed the absence of a qualified regional social worker to fill in until a qualified hire is made.
A facility failed to obtain a valid Do Not Resuscitate Order (DNRO) for a resident with severe cognitive impairment. The resident's sister signed a DNR form, but it was not signed by a physician and not available in the clinical record. Staff interviews revealed confusion about the DNR's validity without the signed form, leading to potential CPR administration despite DNR orders.
A resident with multiple missing and broken teeth was inaccurately assessed in the MDS as having intact natural teeth. Despite informing staff of her dental issues and desire for dentures, the MDS and Nursing Admission Data Collection forms were incorrectly coded, failing to reflect her true dental status. This discrepancy was confirmed by the SSD and MDS Coordinator after reviewing the resident's medical record and conducting interviews.
Two residents with cognitive impairments and functional limitations did not receive necessary grooming and nail care assistance as per their care plans. Despite being dependent on staff for personal hygiene, both residents were observed with long fingernails and facial hair growth. Staff acknowledged the need for grooming but failed to provide consistent care, revealing a deficiency in meeting the personal care needs of these residents.
The facility failed to ensure that two residents participated in activities of their choice, impacting their psychosocial well-being. Observations showed the residents were often in their rooms without engaging in activities, despite care plans indicating preferences for afternoon activities. The DOA assumed staff would facilitate activities without verifying participation, leading to a deficiency in activity provision.
A resident with impaired vision due to glaucoma was not provided timely assistance in replacing lost prescription glasses. Despite multiple observations of the resident without glasses and her reports of the loss, the facility's Social Services department did not take action to address the issue. The resident's care plan included interventions for glasses maintenance, but there was no documented follow-up or grievance filed. The Social Service Director was unaware of the missing glasses, highlighting a communication lapse within the facility.
A resident with impaired cognition and range of motion did not receive proper care to prevent contractures. Despite a care plan requiring splints, the resident was often observed without them, and staff failed to document any refusal. Interviews revealed confusion about responsibilities, and therapy records did not address the resident's needs. The DON could not provide relevant documentation.
The facility did not post the required daily nurse staffing information, as observed over three days. The Administrator admitted that the facility had not posted this information since late February, acknowledging the requirement to display it prominently.
Failure to Implement and Document Infection Control Measures for Scabies
Penalty
Summary
The facility failed to follow its infection prevention and control procedures to prevent the potential spread of scabies in the Memory Care Unit. According to the facility's policy, early identification and management of scabies, including treatment of close contacts, laundering of clothing and bedding, and thorough cleaning of the resident's environment, are required. However, after a resident was diagnosed and treated for scabies at the hospital and subsequently readmitted, the Infection Preventionist (IP) did not document the skin assessments performed on the resident, the roommate, or other close contacts. Additionally, the IP did not document inquiries made to staff regarding rashes or skin issues. The facility did not clean or launder the resident's or roommate's clothing, bedding, or room prior to the resident's return from the hospital, as required by policy. The resident involved had severe cognitive impairment and was dependent on staff for all activities of daily living. The IP acknowledged that no in-services were conducted for staff regarding scabies management, as it was deemed unnecessary. The lack of documentation and failure to implement required infection control measures, including environmental cleaning and staff education, contributed to the facility's noncompliance with its own infection prevention and control program.
Failure to Document Thorough Investigation of Injury of Unknown Origin
Penalty
Summary
The facility failed to document a thorough investigation into an injury of unknown origin for one resident with significant cognitive impairment and physical dependency. The resident, who had diagnoses including a displaced femoral neck fracture, dementia, and anxiety disorder, was found with a bruise on the right medial knee/shin. The initial nursing note indicated the bruise was noticed in the dining room, but the event was unwitnessed, and the resident was unable to describe what happened. The facility's incident investigation form noted the injury was not witnessed, and immediate actions included ordering an X-ray and considering changes to table height. However, there was no documentation of staff or resident statements, and the investigation lacked written accounts from those involved or present at the time. Interviews with the DON and staff revealed inconsistencies and gaps in the investigation process. The DON stated that no one witnessed the incident and that he could not locate statements from the nurse or CNA, with the Unit Manager only verbally asking staff about the event without documentation. A CNA reported discovering the bruise during rounds and notifying the nurse, but did not witness the resident hitting her leg. The LPN recalled being informed of the bruise and assessing it, but also did not witness the event and stated that assumptions could not be made. The lack of documented interviews, statements, and a comprehensive investigation process led to the deficiency cited in the report.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect residents' right to be free from abuse by not having effective processes in place to supervise cognitively impaired residents with known aggressive behaviors. Multiple incidents occurred in which residents with histories of aggression, wandering, or agitation were not adequately supervised, resulting in avoidable resident-to-resident altercations. These altercations led to physical injuries, including scratches and skin tears, among several residents. Specific events included residents hitting, scratching, or otherwise physically assaulting each other in various locations such as hallways, activity rooms, and dining areas. In several instances, residents with dementia or behavioral disturbances wandered unsupervised into other residents' rooms, leading to confrontations and injuries. Staff were observed not supervising residents at critical times, and altercations occurred without immediate staff intervention. The facility's monitoring program, which involved staff rounding every 15 minutes, was not sufficient to prevent these incidents. The facility's own records and staff interviews confirmed that incidents of resident-to-resident aggression continued to occur despite the implementation of monitoring programs. The Director of Nursing acknowledged the high frequency of such altercations, and the Administrator verified multiple incidents of physical abuse between residents. The lack of adequate supervision and ineffective monitoring processes directly resulted in physical harm to several residents and led to a determination of Immediate Jeopardy.
Removal Plan
- The Risk Consultant educated the Administrator and Director of Nursing on abuse, neglect, and exploitation as well as the reporting requirements to the Facility Risk Manager, Nursing Home Administrator, or direct supervisor as they relate to ensuring adequate supervision to ensure the safety of cognitively impaired residents on the secured dementia unit to prevent further incidents of resident-to-resident physical altercations and abuse.
- Administrator educated staff on abuse, neglect, and exploitation as well as the reporting requirements to the Facility Risk Manager, Nursing Home Administrator, or direct supervisor. 147 out of 147 staff members were educated.
- Administrator educated staff on abuse, neglect, and exploitation as they relate to ensuring adequate supervision to ensure the safety of cognitively impaired residents on the secured dementia unit to prevent further incidents of resident-to-resident physical altercations and abuse. 147 out of 147 staff members were trained.
- A Quality Assurance and Assessment meeting was held. Psychiatric services attended with the facility interdisciplinary team and reviewed high risk residents with behaviors. Medications and care planned interventions for behaviors were reviewed.
- Psychiatric service visits were increased for high-risk residents.
- Facility leadership along with the interdisciplinary team planned for enhanced oversight of the secured unit to monitor hallways and common areas for negative behaviors that could lead to a resident-to-resident altercation. Enhanced oversight was initiated.
- Two staff were assigned per shift to conduct enhanced oversight.
- The Administrator or designee is responsible for ensuring that enhanced oversight of the secured unit is in place.
- A qualified activity staff member was assigned to activities in the secured unit.
- A Quality Assurance meeting was conducted to review the effectiveness of the implemented interventions.
Failure to Prevent Resident-to-Resident Altercations Due to Inadequate Supervision
Penalty
Summary
The facility failed to implement adequate supervision and processes on the secured dementia unit to prevent multiple avoidable incidents of resident-to-resident physical altercations among cognitively impaired residents with aggressive behaviors. Over a period of several weeks, numerous residents with severe to moderate cognitive impairment and behavioral disturbances were involved in repeated physical altercations, including hitting, scratching, and grabbing, resulting in injuries such as skin tears, scratches, and emotional distress. These incidents occurred in various locations within the secured unit, including hallways, resident rooms, the dining room, and the activity room, often without staff present to intervene or prevent escalation. Care plans for residents with known aggressive behaviors and wandering tendencies were found to be insufficiently individualized and did not consistently include interventions to ensure adequate supervision or to protect other residents from harm. In several cases, residents with a history of aggression or wandering were not monitored closely enough, leading to altercations when they entered other residents' rooms or were in close proximity to others. Documentation revealed that staff were sometimes unaware of residents' whereabouts or did not witness the altercations, and in some cases, staff only became aware of incidents after hearing raised voices or residents calling for help. Behavioral monitoring and documentation of target behaviors for psychotropic medication use were also lacking or incomplete. The facility's failure to provide necessary structures and supervision resulted in physical injuries to several residents and created a likelihood of serious harm to others. The pattern of incidents demonstrated a lack of effective oversight and intervention for residents at high risk for aggressive behaviors, despite their known diagnoses of dementia, mood disorders, and behavioral disturbances. The deficiency was determined to be at the Immediate Jeopardy level due to the ongoing risk and actual harm experienced by residents on the secured dementia unit.
Removal Plan
- Educate the Administrator and Director of Nursing on ensuring that residents on the secured dementia unit are provided with adequate supervision to prevent incidents of resident-to-resident physical altercations and ensure resident safety.
- Educate staff on ensuring that residents on the secured dementia unit are provided with adequate supervision to prevent incidents of resident-to-resident physical altercations and ensure resident safety.
- Give specific examples of behavioral patterns that potentially lead to resident-to-resident altercations such as wandering patterns and behaviors, proximity of residents, verbal queues, and physical queues.
- Initiate enhanced monitoring and oversight by facility leadership over the secured unit to monitor patient care areas and resident rooms for resident behaviors that could lead to resident-to-resident altercations.
- Ensure that enhanced oversight of the secured unit is in place.
Failure to Screen Employee for Abuse History
Penalty
Summary
The facility failed to protect the health, welfare, and rights of its residents by not ensuring that a dietary aide, referred to as Staff A, was properly screened for a history of abuse, neglect, exploitation, or misappropriation of resident property before beginning employment. The facility's Abuse Prevention Program, which was last updated in November 2024, mandates that potential employees undergo criminal background checks as part of the hiring process to identify any history of abuse or mistreatment. However, Staff A, who was hired on January 14, 2025, was not entered into the Florida Agency For Healthcare Administration's Care Provider Background Screening Clearinghouse, and a new background screening was not obtained despite a break in employment greater than 90 days. The Human Resources Director confirmed that Staff A's employment was not recorded in the background screening clearinghouse, and the last eligibility determination for employment at a Medicaid/Medicare Participating Provider was dated March 23, 2023. Despite this oversight, Staff A worked multiple days in February 2025 without the required screening, which is a violation of the facility's policies and state regulations. This failure to conduct the necessary background checks before employment poses a risk to the residents' safety and well-being.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to honor the right of a resident's health care surrogate (HCS) to be informed about the risks, benefits, side effects, and alternatives of psychotropic medications administered to the resident. The resident, who had severe cognitive impairment and was diagnosed with non-Alzheimer's dementia, was deemed incapable of making informed medical decisions. Consequently, the resident's son was appointed as the HCS. Despite this, the facility administered several psychotropic medications, including Buspirone, Seroquel, Trazodone, and Depakote, without obtaining informed consent from the HCS. Interviews and record reviews revealed that the facility did not have signed consent forms for these medications, and the HCS was not informed about the medications' risks, benefits, side effects, or alternatives. The HCS explicitly stated that he did not consent to the use of antipsychotics and was not informed by the facility staff, who primarily communicated with the business office manager. The psychiatric specialist assumed that the facility obtained the necessary consents but could not recall discussing the medications with the HCS. The medical records lacked documentation of any informed consent discussions with the HCS.
Inadequate Investigation of Resident's Injury
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident with severe cognitive impairment and multiple medical conditions, including dementia and hemiplegia. The resident was dependent on staff for personal care and mobility. On June 20, 2024, staff noted the resident favoring her left arm and screaming when it was touched, leading to an X-ray that showed no fracture. However, on June 23, 2024, the resident complained of pain in her right forearm, which was swollen and discolored. The resident was sent to the emergency room, where a fracture of the right ulna was identified, and the physician noted the bruising appeared old. The facility's investigation into the injury was inadequate, as it did not consider the possibility that the right arm injury occurred on June 20, 2024, when the left arm injury was documented. The investigation lacked documentation of any trauma to the left arm after June 20, 2024, and did not include written statements from staff or an interview with the LPN who initially documented the left arm injury. The facility's failure to conduct a thorough investigation was acknowledged by the current Administrator and Interim Director of Nursing.
Failure to Assist in Resident Relocation
Penalty
Summary
The facility failed to provide adequate social services for the discharge and transfer of a resident diagnosed with toxic encephalopathy and dementia. The resident and their family expressed a desire to relocate the resident to a skilled nursing facility closer to family. The social worker's care plan included assisting with referrals to facilities in the desired area and facilitating a safe discharge. However, the social worker did not actively assist the family in finding a suitable facility, despite the family's request for help and the resident's need for a specialized dementia care unit. The Health Care Surrogate (HCS) for the resident reported that the facility instructed them to find a suitable facility independently, with the facility only offering to fax referrals once a location was identified. The Nursing Home Administrator, who had recently started at the facility, stated that the social services director should assist families in such situations. Despite this, the social worker did not provide the necessary support, resulting in the resident remaining in the facility without the desired relocation closer to family.
Failure in Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure proper communication and documentation between the nursing facility and the dialysis center for a resident receiving dialysis. The facility's policy required the completion of a Dialysis Communication Tool before and after each dialysis session to maintain communication and ensure the resident's stability. However, the review of the resident's records revealed missing forms for several dates and incomplete forms lacking required information, signatures, dates, and times. This deficiency was confirmed by both a registered nurse and a unit manager, who acknowledged the missing and incomplete documentation. The resident involved had multiple diagnoses, including anemia, end-stage renal disease, and heart failure, and was scheduled for dialysis three times a week. Despite the critical nature of the resident's condition, the facility did not adhere to its policy, resulting in a lack of documented communication and assessment of the resident's condition before and after dialysis treatments. This oversight in documentation and communication could potentially impact the resident's care and safety.
Failure to Provide Dental Services for Residents
Penalty
Summary
The facility failed to provide or obtain necessary dental services for four residents, leading to unmet dental needs. Resident #45, who was edentulous, had not received dentures or seen a dentist since admission, despite expressing a desire for dentures. The facility's staff, including nurses and social services, did not follow up on the initial referral for dental services, and there was no documentation of any dental appointments or evaluations in the resident's clinical record. Resident #25 had multiple missing and broken teeth upon admission and expressed a desire to have her remaining teeth extracted for dentures. However, the facility did not arrange for dental services, and the nursing assessment failed to document her dental issues. The resident's requests for dental care were not addressed, and no appointments were scheduled to evaluate or treat her dental concerns. Resident #94 was observed with broken front upper teeth, but her care plan did not reflect her dental status or provide interventions for her dental issues. Similarly, Resident #44 had loose upper dentures that were not addressed by the facility, contributing to his weight loss and insufficient food intake. The facility's staff, including the Registered Dietitian and Social Service Director, were unaware of the resident's dental problems, and no actions were taken to address the loose dentures.
Unqualified Social Worker in Facility
Penalty
Summary
The facility, licensed for 169 beds, failed to ensure that the full-time social worker met the required qualifications. The facility's policy and procedure, effective February 2021, stated that social services staff should have qualifications in line with state and federal regulations, job responsibilities, and applicable licensure laws. However, the current full-time social worker, who assumed the role in March 2024, only held a bachelor's degree in social work and lacked the required one year of supervised social work experience in a healthcare setting. Additionally, there was no signed job description on file for the current social worker. The Regional Consultant confirmed that the previous social worker left in March and that there was no qualified regional social worker available to fill in until a qualified social worker was hired.
Failure to Obtain Valid DNR Order
Penalty
Summary
The facility failed to obtain a Do Not Resuscitate Order (DNRO) in accordance with the advanced directives for a resident with severe cognitive impairment. The resident, who had been diagnosed with anxiety disorder and Parkinson's disease, had a designated durable power of attorney, which did not include health care decisions. Despite the physician issuing a DNR order, the clinical record lacked documentation that the resident had verbalized the wish not to receive CPR in the event of cardiac or respiratory arrest. Additionally, there was no incapacity statement authorizing the resident's sister to make health care decisions on his behalf. The facility's policy required that if a resident or their representative verbalizes the wish not to receive CPR, two staff members must witness and document this request, and the conversation should be printed and placed as the first document in the medical record. However, the yellow Florida DNR form signed by the resident's sister was not signed by the physician and was not available in the clinical record for staff reference. Interviews with staff revealed confusion about the validity of the DNR order without the signed yellow form, indicating that CPR would be performed if the form was not present, even if the computer and orders indicated a DNR status.
Inaccurate MDS Assessment of Resident's Dental Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the dental status of a resident, leading to a deficiency in the assessment process. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, was admitted with multiple missing and broken teeth. Despite informing multiple nursing staff about her dental condition and her desire to have her teeth extracted for dentures, the MDS assessment inaccurately recorded her as having natural teeth that were not broken, cracked, unclean, or loose. The Social Service Director (SSD) and the MDS Coordinator confirmed that the MDS and Nursing Admission Data Collection forms were incorrectly coded, failing to reflect the resident's actual dental status. The SSD and MDS Coordinator both acknowledged the discrepancy after reviewing the resident's medical record and conducting interviews with the resident, who demonstrated her dental issues. This inaccuracy in the MDS assessment could potentially delay or prevent the resident from receiving appropriate dental care.
Deficiency in Grooming and Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with grooming and nail care for two residents who were dependent on staff for activities of daily living. Resident #29, with severe cognitive impairment and functional limitations, was observed multiple times with long fingernails and beard growth, despite being dependent on staff for personal hygiene. The resident's care plan indicated that nail care should be provided on bathing days, yet documentation showed nail care was only provided once in a month. Staff acknowledged the resident's nails were long and needed trimming, but this was not consistently done. Resident #44, who had moderate cognitive impairment and required maximal assistance for personal hygiene, was also observed with long fingernails and facial hair growth. The resident expressed a need for assistance with showering and grooming. The care plan for Resident #44 did not specifically address nail care, and there was no documentation of nail care being provided over a month. Staff confirmed the resident's nails were long and needed trimming, and the resident was unable to perform these tasks independently. Interviews with staff, including the CNA and DON, revealed that the expectation was for residents to receive nail care on shower days. However, there was no specific policy for ADL and nail care, and it was included in the CNA's job description. The lack of consistent nail care and grooming for these residents indicates a deficiency in meeting the personal care needs of dependent residents, as outlined in their care plans.
Failure to Ensure Resident Participation in Activities
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident #24 and Resident #106, participated in activities of their choice, which is essential for maintaining and improving their psychosocial well-being and independence. Observations on multiple days revealed that both residents were consistently found in their rooms, in bed, without engaging in any in-room or out-of-room activities. The television or radio was not on, and there was no evidence of participation in any facility activity programs during the observed times. Resident #24 was admitted with several diagnoses, including anemia, end-stage renal disease, and heart failure, and had a care plan that required staff assistance for activity involvement. The care plan specified that the resident preferred afternoon activities, such as watching television, movies, and participating in group activities. However, documentation showed that the resident's activities were recorded as watching television early in the morning, without confirmation that these activities occurred. The Director of Activities (DOA) admitted to assuming that staff would turn on the television for the resident, without verifying or documenting the actual participation in activities. Similarly, Resident #106, who had a history of anxiety, aphasia, and cognitive communication deficits, was observed in her room without engaging in any activities. The resident's care plan indicated a preference for afternoon activities, including watching television, movies, and socializing outdoors. However, the activity records showed early morning documentation of activities that were not confirmed to have occurred. The DOA acknowledged not observing or confirming these activities, assuming that staff would facilitate them. This lack of oversight and documentation led to the deficiency in providing appropriate activities for the residents.
Failure to Assist Resident with Replacement of Lost Glasses
Penalty
Summary
The facility failed to provide timely assistance to a resident in obtaining replacement prescription glasses, which were lost. The resident, who had a history of impaired vision due to glaucoma, was observed multiple times without her glasses and reported that she had been without them for a while. Despite the resident's impaired cognition and her reliance on glasses to read and enjoy activities like artwork, there was no documented follow-up or action taken by the Social Services department to address the missing glasses. The facility's policy required prompt referrals for vision services, but this was not adhered to in the case of the resident. The resident's care plan initially included interventions to assist with cleaning and placing glasses, and to report any damage to the nurse or social service. However, the Social Services progress notes showed no issues reported since February, and the grievance log did not document any grievance or steps taken to replace the glasses. Interviews with the Social Service Director revealed a lack of awareness about the missing glasses, indicating a communication breakdown within the facility. The resident's need for glasses was documented by the eye doctor, but no appointment was arranged to replace them until the issue was brought to the attention of the Clinical Reimbursement Director.
Failure to Prevent Decline in Range of Motion
Penalty
Summary
The facility failed to provide adequate care and services to prevent a decline in range of motion for a resident with limited range of motion. The resident, who had severely impaired cognition and functional range of motion in both upper extremities, required substantial assistance for daily activities. Despite having a care plan that included the application of orthotic devices (splints) to prevent contractures, the resident was observed multiple times without the splints, and there was no documentation of refusal by the resident. The Treatment Administration Record indicated inconsistencies in the application of the splints, with staff failing to apply them as per the care plan. Interviews with staff revealed a lack of clarity and responsibility regarding the application of the splints. The Licensed Practical Nurse acknowledged that the splints were not always applied, and the Restorative CNAs were not working with the resident due to the assumption that the resident was receiving occupational therapy. However, the therapy records did not address the resident's hand contractures or the use of splints, and the therapy Program Manager confirmed that the resident was not receiving therapy for the contractures. The Director of Nursing was unable to provide notes related to the resident's condition, indicating a lack of oversight and documentation.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with federal regulations requiring the daily posting of nursing staff information. During observations on three consecutive days, the required staffing information was not posted or made available to residents and visitors. An interview with the Administrator revealed that the facility had not posted the required daily staffing information since February 29, 2024. The Administrator acknowledged the requirement to post this information daily in a prominent location within the facility.
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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