The Bristol Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tampa, Florida.
- Location
- 1818 E Fletcher Ave, Tampa, Florida 33612
- CMS Provider Number
- 105140
- Inspections on file
- 29
- Latest survey
- January 5, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at The Bristol Care Center during CMS and state inspections, most recent first.
A resident with hemiplegia and hemiparesis following a cerebral infarction had a personal trust fund with balances well above the $2,000 SSI resource limit and received monthly Social Security deposits, while Medicaid records showed a $0 patient liability. The BOM stated the room and board charge was incorrect, but when surveyors requested proof that the resident or representative had been notified that the account was within $200 of the SSI asset limit, no documentation was available, and no policy or procedure for such notifications could be produced.
A resident with major depressive disorder and chronic pain repeatedly reported not receiving an expected $130 Personal Needs Allowance check from the state and stated she had been asking about it for an extended period without results. The grievance log showed a grievance involving dietary, social services, and the business office marked as resolved, but the underlying grievance document was unavailable. The Business Office Manager acknowledged the resident began complaining months after admission, noted that the resident had previously received the $130 at another facility, and indicated that limited contacts were made with DCF and a Medicaid specialist about the missing payment. However, there was no documentation of timely investigation, written grievance findings, or effective follow-up to resolve the resident’s complaint, contrary to the facility’s grievance policy and the business office job responsibilities.
A resident did not receive the prescribed Pregabalin 75 mg three times a day due to a failure in obtaining the necessary prescription from the physician. Despite attempts to contact the pharmacy, the medication was not available, and there was no documentation of physician notification. The facility's process for handling new admissions and controlled medications was not followed, leading to the deficiency.
A resident with flaccid hemiparesis was found on the floor after being left in the bathroom for privacy. CNAs moved the resident back to a wheelchair before a nurse could assess him, contrary to facility protocol. The nurse assessed the resident only after he was moved, and the DON confirmed that CNAs should not move residents post-fall until assessed by a nurse.
A resident with significant medical conditions was found on the floor by facility staff and moved by CNAs without a nurse's immediate assessment. The nurse was informed after the resident was already moved, contrary to facility protocol requiring a nurse's assessment before moving a resident post-fall.
A resident did not receive the prescribed Pregabalin 75 mg three times a day due to the facility's failure to ensure the medication was available and administered. The pharmacy did not have the prescription, and there was insufficient follow-up by staff to obtain it, resulting in a deficiency.
The facility failed to update PASRRs for several residents with mental disorders, leading to deficiencies in care planning. A resident with multiple mental health diagnoses did not have an updated PASRR, and another resident's PASRR was not updated upon admission. Other residents had incomplete PASRRs, and the Social Services Director relied on the system for notifications, which did not occur.
The facility failed to provide necessary care for a resident with an immune deficiency syndrome, including timely lab work follow-up and communication of results. Another resident's request to change from a mechanical soft diet to a regular diet was not addressed, and routine lab work for a resident with chronic conditions was not conducted as ordered. The facility lacked policies for coordinating care and documenting refusals, leading to these deficiencies.
A LTC facility failed to consistently apply orthotic devices for residents, leading to deficiencies in care. One resident's orthotic was left out of reach, with no staff assigned to apply it. Another resident with contractures did not consistently receive prescribed orthotics, and a third resident's orthotic application was inconsistently documented. Staff interviews revealed confusion and lack of clear processes for orthotic application, particularly on weekends.
The facility failed to maintain a medication error rate below five percent, resulting in a 13.79% error rate. An LPN administered an incorrect dosage of Calcium Carbonate to a resident, and another LPN failed to administer three medications to a different resident, despite signing them off as given. The facility's policy on medication administration was not followed, leading to these errors.
A resident with moderate cognitive impairment reported missing clothing to the laundry staff, but no grievance was filed, and the issue remained unresolved. The facility's grievance policy was not followed, as confirmed by interviews with the Social Services Director, laundry supervisor, and DON.
A facility failed to thoroughly investigate an alleged abuse incident where a nurse reportedly slapped a resident's hand during a medication pass. The investigation was limited to interviews with the involved parties and did not include other residents who received care from the accused nurse. Additionally, there was a delay in obtaining statements from the residents involved, contrary to the facility's policy requirements.
Two residents in an LTC facility did not receive showers according to their care plans and preferences. One resident, with hemiplegia, preferred showers but documentation was inconsistent, and staff interviews revealed discrepancies in recording practices. Another resident, dependent on staff for bathing, had inaccurate records of bathing after being transferred to an acute care facility. The facility's policy on ADLs was not followed, leading to a deficiency in maintaining residents' hygiene and preferences.
A facility failed to obtain consent from a resident's POA before using funds to purchase a chair for a bed-bound resident. The BOM and DOR did not contact the family, and the OT assumed the BOM would notify them. The purchase was part of a Medicaid spend down, but the lack of communication and consent led to a grievance. The facility's policy requires informing residents of charges to their funds, which was not followed.
A resident's assessment was not updated within the required three-month period, leading to a deficiency. The resident, with multiple diagnoses, had a Quarterly MDS that was completed late. The MDS Coordinator admitted the MDS was closed late and was unsure of the exact due date, indicating it might have been due earlier.
A facility failed to conduct a Level II PASRR for a resident with serious mental illness, despite diagnoses of Major Depressive Disorder and Bipolar Disorder. The resident's initial Level I PASRR did not indicate the need for further evaluation, but a subsequent report identified the need for a Level II review. The facility's psychiatric meeting documentation also indicated the need for a Level II review, which was not conducted. The Social Service Director noted that the facility had a process for updating PASRRs but did not resubmit the resident for a Level II review after adding an anxiety diagnosis.
The facility failed to properly store urinary drainage bags for two residents, leading to potential infection risks. A resident's drainage bag was observed hanging from a wheelchair with tubing on the floor, while another resident's bag was on the floor under an over-bed table. Staff confirmed the improper storage, and the facility's policy lacked specific storage instructions.
A facility failed to obtain a physician order before administering oxygen to a resident with COPD and other conditions. The resident had been using oxygen therapy at night without a physician's directive, as confirmed by the resident and the DON. The facility's policy mandates a physician order for oxygen administration, which was not followed.
Failure to Notify Resident of Trust Account Approaching SSI Resource Limit
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident or responsible party when the resident’s personal trust account balance came within $200 of the $2,000 Supplemental Security Income (SSI) resource limit. The resident, admitted in 08/2022, had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and required assistance with personal care. Review of the resident’s personal trust fund statements showed a balance of $7,871.13 on 07/01/2025, $5,469.30 on 11/04/2025, $6,264.65 on 12/04/2025, and $6,216.12 on 01/02/2025, with monthly deposits of $964.00 from 07/2025 through the survey date. The Business Office Manager (BOM) stated the resident was receiving a Social Security payment of $964.00 and acknowledged that the patient liability (room and board charge) was wrong. A Notice of Case Action from the Department of Children and Families dated 02/11/2025 documented that the resident had Medicaid eligibility with a $0.00 patient liability for 12/2024, 01/2025, 02/2025, and 03/2025 ongoing. Despite this, when surveyors requested evidence on 01/05/2026 that the resident or resident representative had been notified that the resident’s assets were within $200 of the $2,000 limit, no documentation was provided. When asked the same day for a policy and procedure for notifying residents when their assets are within $200 of the $2,000 asset limit, the BOM was unable to provide any such document. These findings show that the facility did not provide required notification or have documented procedures for this notification requirement.
Failure to Implement Grievance Process for Resident’s Missing PNA Funds
Penalty
Summary
The deficiency involves the facility’s failure to implement its grievance process and promptly resolve a resident’s ongoing complaint regarding non-receipt of a $130 Personal Needs Allowance (PNA) check from the Department of Children and Families (DCF). Resident #8, admitted with diagnoses including major depressive disorder and chronic pain, reported receiving a $30 SSI check and expecting an additional $130 state check that she had not received despite asking about it since 2024. During interview, she stated she had been requesting assistance with this issue with nothing happening. The facility’s grievance log for December 2024 showed a grievance from this resident involving dietary, social services, and the business office, marked as resolved the next day, and the Social Service Director stated the resident had requested to see the Business Office Manager (BOM) during that period. However, the actual grievance document was not available for review prior to survey exit. The BOM confirmed the resident was admitted in September 2024 and began complaining about the missing $130 check approximately three to four months after admission, requesting information on why she was not receiving it. The BOM stated there was likely a grievance and that social services would handle it, and reported sending a DCF fax cover sheet in early September 2025 noting the resident was not receiving the $130 state check and asking DCF to update from the time of admission. The BOM also stated the matter was turned over to the facility’s contracted Medicaid Specialist, and provided an email indicating the specialist had made an inquiry to DCF about the PNAS check in September 2025. No further information was available to show follow-up efforts or resolution of the PNAS issue with DCF prior to survey entrance. This inaction occurred despite facility policy requiring prompt efforts to resolve grievances, written investigation and reporting by the grievance officer within five working days, and maintenance of grievance records, as well as the BOM’s job description requiring maintenance of written records of resident complaints and follow-up with Medicaid in a timely manner.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to follow physician orders for medication administration for one resident, who was admitted with a medical diagnosis that included subcortical and flaccid conditions affecting the right dominant side. The resident was prescribed Pregabalin 75 mg to be administered three times a day, starting from the day of admission. However, the resident did not receive the medication during five administration opportunities, as documented in the medical records. The deficiency arose because the prescription for Pregabalin was not sent to the pharmacy, and the medication was not available in the emergency drug kit. Despite the nurses' attempts to contact the pharmacy, they did not have the prescription, and there was no documentation indicating that the physician was notified to provide the necessary prescription. The facility's emergency medication drug list showed that Pregabalin 25 mg was available, but the required 75 mg dosage was not administered. Interviews with the nursing staff and the Director of Nursing revealed that the facility's process for handling new admissions and controlled medications was not followed. The nurses were expected to notify the physician and document the need for a prescription, but this was not done. The Director of Nursing confirmed that the medication should have been administered as prescribed, and the nurses should have continued to contact the physician until the medication was delivered.
Plan Of Correction
Immediate actions taken for residents found to have been affected: Resident #1 was discharged from the facility on. Identification of other residents having the potential to be affected: Current residents in the facility were reviewed by to ensure their medications requiring hard scripts were available in the medication cart. No other residents were affected by the deficient practice. Actions taken/systems put into place to reduce risk of future occurrence: Staff Development Coordinator/designee will re-educate licensed nurses by to ensure physicians are notified when a hard script is needed for a new medication and will continue to follow up with physician and/or pharmacy until medication is received. How the corrective actions will be monitored to ensure the practice will not recur: DON/designee will review new admissions to ensure hard scripts were received or sent to pharmacy to ensure medication is delivered and available to the resident 3 times a week for 2 weeks then 2 times a week for 2 weeks then weekly. The administrator will oversee audit completion and report findings in the monthly Risk Management/QA Committee meeting for 3 months or until substantial compliance is achieved.
Failure to Follow Protocol for Resident Fall Assessment
Penalty
Summary
The facility failed to provide adequate and appropriate health care by not ensuring that a resident was assessed immediately by a nurse after being found on the floor. The incident involved a resident who was originally admitted with diagnoses including flaccid hemiparesis affecting the right dominant side. On the day of the incident, the resident was assisted to the bathroom by two CNAs and left there for privacy. Shortly after, the resident was found on the floor by a housekeeper, and the CNAs lifted the resident back into a wheelchair before a nurse could perform an assessment. Interviews with staff revealed that the protocol requires a nurse to assess a resident before they are moved after a fall. However, in this case, the CNAs moved the resident without waiting for the nurse's assessment. The nurse, who was administering medication in another room at the time, assessed the resident only after the CNAs had already moved him. The Director of Nursing confirmed that CNAs are not allowed to move a resident after a fall until a nurse has conducted an assessment, which was not followed in this instance.
Plan Of Correction
D-Right to Adequate and Appropriate Health Care Immediate actions taken for residents found to have been affected: Resident #1 was discharged from the facility on. Identification of other residents having the potential to be affected: Residents within the past 30 days were reviewed to ensure they were evaluated by a licensed nurse prior to being moved to the bed or chair. No other residents were affected by the deficient practice. Actions taken/systems put into place to reduce risk of future occurrence: Staff Development Coordinator/designee will re-educate licensed clinical staff by on ensuring residents with are evaluated by a licensed nurse prior to the resident being moved to the bed or chair. How the corrective actions will be monitored to ensure the practice will not recur: DON/designee will review residents with weekly for 4 weeks then monthly x3 months to ensure residents are being evaluated by the nurse prior to being moved to the bed or chair. The administrator will oversee audit completion and report findings in the monthly Risk management/QA committee.
Failure to Assess Resident After Fall
Penalty
Summary
The facility failed to ensure that a resident was assessed immediately by a nurse after being found on the floor by facility staff. The incident involved a resident with a history of significant medical conditions, including subcortical and flaccid paralysis affecting the right dominant side. On the day of the incident, the resident was placed on the toilet by two CNAs and left alone for privacy. Shortly after, the resident was found on the floor by a housekeeper, and the CNAs assisted the resident back into a wheelchair without waiting for a nurse to conduct an assessment. Interviews with staff revealed that the nurse, who was administering medication in another room, was informed of the incident after the CNAs had already moved the resident. The nurse assessed the resident only after the CNAs had placed the resident in a wheelchair. Facility protocol dictates that CNAs should notify a nurse immediately and wait for an assessment before moving a resident who has fallen. The Director of Nursing and other staff confirmed that the CNAs did not follow the required protocol, which includes notifying the nurse, conducting an assessment, and completing an incident report before moving the resident.
Plan Of Correction
F 684 D- Quality of Care Immediate actions taken for residents found to have been affected: Resident #1 was discharged from the facility on. Identification of other residents having the potential to be affected: Residents within the past 30 days were reviewed to ensure they were evaluated by a licensed nurse prior to being moved to the bed or chair. No other residents were affected by the deficient practice. Actions taken/systems put into place to reduce risk of future occurrence: Staff Development Coordinator/designee will re-educate licensed clinical staff by on ensuring residents with are evaluated by a licensed nurse prior to the resident being moved to the bed or chair. How the corrective actions will be monitored to ensure the practice will not recur: DON/designee will review residents with weekly for 4 weeks then monthly x3 months to ensure residents are being evaluated by the nurse prior to being moved to the bed or chair. The administrator will oversee audit completion and report findings in the monthly Risk management/QA committee.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide physician-ordered medication for a resident, resulting in a deficiency. The resident was admitted to the facility with a hospital discharge medication list that included Pregabalin 75 mg to be administered three times a day. However, the resident did not receive the medication during five administration opportunities from admission until discharge. The medication administration record indicated that the medication was not available, and the pharmacy did not have the prescription. Interviews with staff revealed that the medication was not in the medication cart, and the pharmacy was contacted but did not have the prescription. The staff did not remember if the physician was contacted to obtain the prescription. The facility's emergency medication drug list showed that Pregabalin 25 mg was available, but the required 75 mg dose was not administered. The Director of Nursing confirmed that Pregabalin is a controlled medication requiring a prescription and that the medication was not delivered because the pharmacy did not receive a prescription. The facility's policy on administering medications states that medications should be administered safely, timely, and as prescribed. The Director of Nursing indicated that if a controlled medication is not available, the physician should be notified, and there should be documentation of this notification. Despite these procedures, the resident did not receive the prescribed Pregabalin, and there was a lack of documentation and follow-up to ensure the medication was provided.
Plan Of Correction
F 755 D- Pharmacy Services/Procedures/Pharmacist/Records Immediate actions taken for residents found to have been affected: Resident #1 was discharged from the facility on Identification of other residents having the potential to be affected: Current residents in the facility were reviewed by to ensure their medications requiring hard scripts were available in the medication cart. No other residents were affected by the deficient practice. Actions taken/systems put into place to reduce risk of future occurrence: Staff Development Coordinator/designee will re-educate licensed nurses by to ensure physicians are notified when a hard script is needed for a new medication and will continue to follow up with physician and/or pharmacy until medication is received. How the corrective actions will be monitored to ensure the practice will not recur: DON/designee will review new admissions to ensure hard scripts were received or sent to pharmacy to ensure medication is delivered and available to the resident 3 times a week for 2 weeks then 2 times a week for 2 weeks then weekly. The administrator will oversee audit completion and report findings in the monthly Risk Management/QA Committee meeting for 3 months or until substantial compliance is achieved.
Failure to Update PASRRs for Residents with Mental Disorders
Penalty
Summary
The facility failed to complete or update the Pre-admission Screening and Resident Reviews (PASRRs) for several residents with mental disorders or intellectual disabilities. This deficiency was identified for five out of eight residents reviewed. The PASRR process is crucial for determining the appropriate level of care and services required for residents with mental health diagnoses. The failure to update these screenings can lead to inadequate care planning and service provision. Resident #228 was admitted with multiple mental health diagnoses, including generalized anxiety disorder, bipolar disorder, and depression. A new diagnosis of brief psychotic disorder was added, but the Level I PASRR was not updated, and a Level II PASRR was not submitted. The Social Services Director (SSD) acknowledged the oversight, citing a timing issue in reviewing and updating the PASRR. Other residents, such as Resident #145 and Resident #163, also had outdated or incomplete PASRR screenings. Resident #145's PASRR was not updated upon admission to the current facility, and Resident #163's PASRR did not mark qualifying diagnoses. Resident #25 and Resident #60 had similar issues, with their PASRRs not reflecting their current mental health diagnoses or the need for a Level II evaluation. The SSD admitted to relying on the system to notify her of the need for a Level II PASRR, which did not occur, leading to these deficiencies.
Deficiencies in Resident Care and Lab Work Follow-Up
Penalty
Summary
The facility failed to provide necessary care and services for a resident with an immune deficiency syndrome. The resident expressed concerns about not receiving timely blood work results to assess the effectiveness of their antiretroviral therapy medication. Despite having a care plan that included obtaining labs as ordered and reporting results to the physician, there was a lack of follow-up on abnormal lab results. The Director of Nursing (DON) admitted to not being aware of the resident's treatment for immune deficiency syndrome and did not ensure timely lab work follow-up. The resident also reported a negative experience with a health department appointment, which led to a lack of further appointments being scheduled. Another resident, who had been on a mechanical soft diet due to previous speech therapy recommendations, expressed a desire to switch to a regular diet. Despite being cognitively intact and having communicated this request to the staff, there was no follow-up on the diet change. The resident's speech therapy had been discontinued due to exhausted benefits, and there was no recent evaluation to reassess the dietary needs. The facility lacked a policy for coordinating care with therapy, which contributed to the oversight. Additionally, the facility failed to maintain routine lab work for a resident with multiple diagnoses, including chronic kidney disease and diabetes. The resident's lab work, ordered to be completed on a specific date, was not found in the electronic results tab, indicating it was not conducted. The DON later provided a lab log showing the bloodwork had been refused, but there was no documentation of this refusal in the resident's records. This lack of documentation and follow-up on lab work orders highlights a deficiency in the facility's care processes.
Inconsistent Application of Orthotic Devices in LTC Facility
Penalty
Summary
The facility failed to provide appropriate care for residents requiring orthotic devices, as evidenced by observations, record reviews, and interviews. Resident #123 was observed with a left-hand brace/splint lying out of reach, and the resident reported that no staff applied the orthotic device, relying instead on a family member. The resident's care plan did not include instructions for applying the orthotic, and staff interviews revealed confusion about who was responsible for its application. The Director of Rehabilitation noted that the resident had trialed a splint but did not require it anymore, yet the resident expressed a need for the device. Resident #14 was observed with contractures and was not wearing the prescribed orthotic devices. The resident's care plan included orders for bilateral palm guards and elbow splints, but documentation and staff interviews indicated inconsistent application of these devices. The Director of Rehabilitation reported that a palm guard was missing and had been discarded by a CNA due to soiling, despite being washable. The facility lacked a clear process for applying splints on weekends, leading to further inconsistencies in care. Resident #31 was observed with orthotic devices not being consistently applied as per the care plan. The resident's records indicated orders for wearing a right elbow orthotic and a right-hand splint, but observations and documentation showed these were not consistently applied or documented. Interviews with staff revealed that the rehab tech was responsible for applying the splints, but there was no scheduled time for application, and documentation was incomplete. The facility's policies on range of motion and specialized rehabilitative services were not adequately followed, contributing to the deficiencies observed.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 13.79% error rate during the observed period. Twenty-nine medication administration opportunities were observed, and four errors were identified involving two residents. For Resident #135, a Licensed Practical Nurse (LPN) administered a 750 mg Calcium Carbonate chewable tablet instead of the prescribed 600 mg tablet. This discrepancy was noted during a review of the resident's active medication orders. For Resident #220, another LPN prepared and administered several medications but failed to administer Metoprolol 50 mg, Omeprazole 20 mg, and Metformin HCL 1000 mg, despite signing them off as given. The LPN later admitted to not seeing these medications on the screen during the initial administration and claimed to have administered them later. However, the Medication Admin Audit Report indicated that all medications were signed off as given at the same time, raising concerns about the accuracy of the administration records. The facility's policy on medication administration emphasizes the importance of verifying the right medication, dosage, and time, which was not adhered to in these instances.
Failure to Address Resident's Grievance on Missing Clothing
Penalty
Summary
The facility failed to address a resident's grievance regarding missing clothing, which was reported by the resident during a facility tour. The resident, who had a moderate cognitive impairment with a BIMS score of 11, stated that she was missing a couple of pairs of pants and undershirts that her family had brought in. Despite informing the laundry staff about the missing items approximately three weeks prior, no grievance was filed on her behalf, and the issue remained unresolved. Interviews with facility staff revealed that the Social Services Director had not received any grievances from the resident or staff, and the grievance log showed no entries for this resident. The laundry supervisor and her assistant confirmed that the resident had reported the missing clothes, but a grievance was not initiated as per the facility's policy. The assistant laundry supervisor admitted to providing the resident with clothes from the donations pile instead of filing a grievance. The Director of Nursing stated that a grievance should have been initiated if the resident reported missing laundry. The facility's grievance policy requires prompt efforts to resolve grievances, which was not adhered to in this case.
Incomplete Investigation of Alleged Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged abuse incident involving a resident and a staff member. The incident was reported by a roommate who claimed that a nurse slapped the resident's hand during a medication pass. The resident involved, who had intact cognition and a history of mental health conditions, initially denied any mistreatment when interviewed. However, later statements indicated that the nurse may have lightly slapped the resident's hand after the resident pushed the nurse's hand away. The facility's investigation was incomplete as it only involved interviews with the directly involved parties and did not include other residents who received care from the accused staff member. Additionally, there was a delay in obtaining statements from the involved residents, which took seven days instead of the typical five-day window. The facility's policy required interviews with other residents and a review of all events leading up to the incident, which was not fully adhered to. The report highlights that the facility's abuse investigation guidelines were not thoroughly followed, as the investigation did not extend beyond the immediate parties involved. The facility's policy emphasizes the importance of protecting residents from abuse and ensuring a comprehensive investigation, which was not achieved in this case.
Failure to Provide Showers Per Care Plan and Resident Preference
Penalty
Summary
The facility failed to ensure that two dependent residents received showers according to their plan of care and personal preferences. Resident #123, who has diagnoses including hemiplegia and hemiparesis, expressed a preference for showers over bed baths, which was documented as very important in their care plan. However, the facility's documentation did not consistently indicate whether the resident received showers as preferred, with discrepancies noted in the timing and type of bathing provided. Interviews with staff revealed inconsistencies in documentation practices, with some staff unaware of the specific requirements for recording the type of bathing provided. Resident #283, who was dependent on staff for bathing and had a history of medical conditions such as hypotension and myocardial infarction, also did not receive showers as per their care plan. The facility's documentation showed that the resident was dependent on staff for bathing, but it did not specify the type of bathing received. Additionally, there were instances where the documentation inaccurately recorded bathing after the resident had been transferred to an acute care facility, indicating a lack of accurate record-keeping. The facility's policy on supporting activities of daily living (ADLs) emphasizes the importance of providing care to maintain or improve residents' abilities to perform ADLs. However, the facility did not adhere to this policy, as evidenced by the lack of proper documentation and failure to provide showers according to the residents' preferences and care plans. This deficiency highlights a gap in the facility's ability to ensure that residents receive the necessary care and services to maintain their hygiene and personal preferences.
Failure to Obtain Consent for Resident Fund Usage
Penalty
Summary
The facility failed to obtain consent from the designated Power of Attorney (POA) before utilizing funds from a resident's account to purchase a chair. The resident, who was incapacitated and bed-bound, had a chair purchased for her without the knowledge or consent of her responsible party or POA. The Business Office Manager (BOM) and Director of Rehabilitation (DOR) confirmed that they did not attempt to contact the resident's family or POA regarding the purchase. The Occupational Therapist (OT) conducted an assessment and determined the need for a chair, but did not notify the family, assuming the BOM would do so. The facility's policy requires residents to be informed in advance of any charges to their personal funds, which was not adhered to in this case. The resident's responsible party expressed dissatisfaction with the purchase, stating that the resident did not use the chair and was in hospice care. The BOM stated that the purchase was made as part of a Medicaid spend down, and the facility was acting as the resident's payee at the time. Despite the OT's assessment and trial of the chair, the lack of communication and consent from the POA led to the grievance. The Nursing Home Administrator acknowledged the POA's concerns and planned to address the issue, but the deficiency highlights a failure in the facility's process for managing resident funds and obtaining necessary consents.
Late Submission of Resident Assessment
Penalty
Summary
The facility failed to update a resident's assessment within the required three-month period, resulting in a deficiency. Resident #196, who was admitted with diagnoses including cerebral infarction, confusional arousals, white matter disease, cognitive communication deficit, and major depressive disorder, had a Quarterly Minimum Data Set (MDS) that was completed late. The MDS, which was supposed to be completed by a specific due date, was closed on 01/03/25 and not submitted until 01/07/25. During an interview, the MDS Coordinator, Staff A, acknowledged that the MDS was closed late and was unsure of the exact due date, suggesting it might have been due on 01/02/25. The delay in closing the MDS even by a minute past the due date was considered a late submission.
Failure to Conduct Level II PASRR for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to submit a resident for a Level II Pre-admission Screening and Resident Review (PASRR) despite the presence of serious mental illness diagnoses. The resident, who was observed lying in bed and covering her head with a blanket, had an admission comprehensive assessment indicating active psychiatric diagnoses, including depression and bipolar disorder. The initial Level I PASRR, completed by another facility, did not indicate a need for a Level II evaluation. However, a subsequent Level II PASRR Determination Summary Report identified the resident as having a Serious Mental Illness, with diagnoses such as Major Depressive Disorder and Bipolar Disorder, and recommended a Level II review if there was a significant change in mental status. Despite these findings, a later Level I PASRR screening did not require a Level II evaluation, and the facility's psychiatric meeting documentation indicated the need for a Level II review, which was not conducted. The Social Service Director stated that the facility had a process for updating PASRRs but did not resubmit the resident for a Level II review after adding an anxiety diagnosis, as the resident already had a previous Level II evaluation. The facility's policy requires all new admissions to be screened for mental disorders and referred for a Level II evaluation if necessary, but this process was not followed in this case.
Improper Storage of Urinary Drainage Bags
Penalty
Summary
The facility failed to ensure proper storage of urinary drainage bags and tubing for two residents with urinary catheters, leading to potential infection risks. Resident #91 was observed with a urinary drainage bag hanging from the wheelchair frame under the seat, with the catheter tubing dragging on the floor. This was confirmed by a registered nurse who assisted the resident into the shower room to adjust the tubing. The resident's treatment administration record indicated that staff were required to ensure the use of a securing device for the urinary catheter, perform catheter care with soap and water every shift, and change the urinary catheter bag and tubing as needed for blockage or signs of infection. Similarly, Resident #18 was observed with a urinary drainage bag on the floor under the over-bed table. A certified nursing assistant acknowledged that the bag should not be on the floor and repositioned it to hang from the bed frame. The resident's treatment administration record also required staff to ensure the use of a securing device for the urinary catheter every shift, perform catheter care with soap and water every shift, and change the urinary catheter bag and tubing as needed. The Director of Nursing/Infection Preventionist confirmed that urinary bags should not be on the floor, although the facility's urinary catheter care policy did not specify how the drainage bag should be stored.
Lack of Physician Order for Oxygen Administration
Penalty
Summary
The facility failed to ensure a physician order was available prior to providing oxygen administration for a resident. An observation revealed an oxygen concentrator with a nasal cannula at the bedside of a resident who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), ataxia, heart failure, and major depressive disorder. A review of the physician orders showed no current order for oxygen administration, despite the resident having been provided with oxygen therapy starting on a specific date as noted in the Nurses Note. Interviews with the resident and the Director of Nursing (DON) confirmed the absence of a physician order for the oxygen therapy. The resident stated that he had been using oxygen therapy at night for a couple of weeks and managed the oxygen concentrator himself. The DON acknowledged that a physician order is necessary to guide staff on the oxygen administration specifics, such as the number of liters, frequency, and form of delivery. The facility's policy on oxygen administration also requires verification of a physician's order before proceeding with the procedure.
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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