Westside Oaks Rehabilitation & Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jacksonville, Florida.
- Location
- 2061 Hyde Park Rd, Jacksonville, Florida 32210
- CMS Provider Number
- 105287
- Inspections on file
- 27
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 19 (4 serious)
Citation history
Health deficiencies cited at Westside Oaks Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
Administration and nursing staff failed to enforce the facility’s Smoking/Vaping policy and control smoking materials for multiple smokers, including oxygen‑dependent residents. A resident with COPD and intact cognition, known to smoke in his room and sometimes while on oxygen, repeatedly retained cigarettes and a lighter despite staff awareness and prior incidents. One evening, a CNA observed this resident smoking in his room with a nasal cannula in place; the cannula ignited, causing facial burns and respiratory distress that required emergency transfer and intubation. Other residents, including two oxygen‑dependent smokers and one non‑oxygen‑dependent smoker, reported routinely keeping cigarettes and lighters on their person, sometimes smoking in their rooms or bathrooms, and refusing to surrender supplies due to fear of theft. Smoking evaluations and care plans often classified these residents as safe smokers, sometimes without supervision, and documentation did not reflect their ongoing noncompliance, while a CNA stated that leadership had long been aware that residents retained smoking materials and smoked in non‑designated areas without effective action.
A facility failed to use QAPI and adverse event data to address ongoing unsafe smoking and oxygen practices. A cognitively intact resident with COPD and continuous O2, who had a documented history of smoking in his room and refusing to relinquish cigarettes, again smoked in his room while on O2, igniting his nasal cannula and sustaining facial burns and respiratory distress requiring emergent hospital transfer. Other cognitively intact smokers, including two who used O2, routinely kept cigarettes and lighters on their person, admitted to smoking in rooms or bathrooms, and did not surrender smoking materials to staff despite posted no‑smoking/O2 signs and care plans that labeled them as safe smokers. CNAs reported that most smokers refused to give up supplies, that they had repeatedly informed leadership about in‑room smoking by O2‑dependent residents, and that leadership did not implement effective changes. Staff education on smoking and O2 safety was limited to self‑reading folders with sign‑in sheets, and there was no effective QAPI‑driven root cause analysis or performance improvement to prevent recurrence, resulting in Immediate Jeopardy at a widespread level.
The facility failed to enforce its Smoking/Vaping policy for multiple smokers, including oxygen‑dependent residents, allowing them to keep cigarettes and lighters on their person or in their rooms and to smoke inside, including while oxygen was in use. One oxygen‑dependent resident with COPD and intact cognition had a documented history of smoking in his room and bathroom despite prior staff observations and care plan interventions requiring supervised smoking. Staff, including CNAs, an RN, and the DON, were aware of repeated in‑room smoking and residents’ refusal to surrender smoking materials but generally did not confiscate supplies, relying instead on notifying management while rounding remained infrequent. This inaction culminated in an event where a resident’s nasal cannula ignited while he smoked in his room, causing second‑degree facial burns and respiratory distress, and surveyors later observed other smokers, including another oxygen‑dependent resident and a roommate of an oxygen‑dependent resident, leaving the designated smoking area and returning to oxygen‑posted rooms with cigarettes and lighters still in their possession.
The facility failed to enforce its Smoking/Vaping policy and provide adequate supervision for smokers, including oxygen‑dependent residents. Multiple cognitively intact residents routinely kept cigarettes and lighters on their person or in their rooms, did not surrender them to staff, and some admitted to smoking in bathrooms and rooms despite posted “Oxygen in Use/No Smoking” signs. Staff, including CNAs, an RN, and the DON, were aware that a resident on continuous O2 with COPD repeatedly smoked in his room, yet smoking materials were not consistently confiscated and supervision was limited due to workload. One evening, a CNA entered a room, smelled smoke, and saw this resident smoking when his nasal cannula ignited, causing second‑degree facial burns and respiratory distress that required emergency transfer and intubation. Other residents and staff reported ongoing indoor smoking, infrequent rounding, and long‑standing issues with residents hiding cigarettes and lighters, while smoking evaluations and care plans continued to label several residents as safe, often without supervision, and documentation did not reflect their noncompliance. Immediate Jeopardy at level K was identified and remained ongoing at survey exit.
A resident with COPD on oxygen via nasal cannula smoked a cigarette in his room, igniting the cannula and sustaining second‑degree facial burns and respiratory distress that required EMS response, intubation, and transfer to an acute‑care trauma/burn unit. Facility documentation, including an Ad Hoc QAPI meeting form, described the event as a resident smoking in the room with oxygen in place and sustaining second‑degree burns, and the facility’s policy defined such an event requiring transfer to a higher level of care as a reportable adverse incident. However, the monthly reportable log listed zero adverse incidents, and the Administrator, DON, and CEO all confirmed that no adverse incident report was submitted to AHCA, later acknowledging that the event met the policy’s definition of a reportable adverse incident.
Inaccurate PASRRs for residents with MDs/IDs: The facility failed to document identified MDs/IDs on PASRRs for seven residents whose records showed diagnoses such as schizophrenia, schizoaffective disorder, bipolar disorder, depression, anxiety, psychosis, dementia with behavioral disturbance, and alcohol abuse/dependence. Their care plans also reflected behaviors including aggression, elopement risk, sexually inappropriate behaviors, disruptive sounds, and impaired cognition. The SSD and DON stated PASRRs were reviewed at admission, but the DON later confirmed the PASRRs were inaccurate because diagnoses had been excluded.
Failure to provide basic grooming and nail care: multiple residents were observed with dirty, overgrown, or jagged fingernails, one resident had oily, unshampooed-looking hair, and another had persistent chin hair. Interviews with residents and nursing staff showed that ADL/grooming care was not being consistently provided or documented, despite care plans identifying dependence or assistance needs for hygiene, bathing, and personal care.
Unqualified Full-Time Social Worker: The facility failed to verify that the full-time SSD met the required education and licensure qualifications. Review of the SSD’s personnel file showed no bachelor’s degree in social work or similar human services field, and the Administrator reported that requested MSW, transcripts, and social worker license were never provided during the survey.
A resident with moderate cognitive impairment, bilateral amputations, and significant ADL dependence was observed in a dark bed area without a light source, while other beds in the room had wall-mounted fixtures. The resident said the darkness bothered him, and the D of Housekeeping verified that the bed area had no light fixture and had not reported it to Mntc.
Two residents with physician orders for oxygen therapy were observed receiving oxygen at incorrect flow rates. One resident with COPD had an order for 2 L/min via NC but was found at 2.5 L/min, and another resident with COPD and other diagnoses had an order for 2 L/min PRN but was observed twice with the concentrator set at 5 L/min. Staff interviews confirmed the settings did not match the orders.
Missing and Stained Privacy Curtains: The facility failed to provide privacy curtains in several resident bedrooms and failed to keep two privacy curtains free of heavy staining. Multiple residents were observed in rooms without a privacy curtain track or curtain, and two bed curtains were seen with black scratch marks and dark spots. The DON of Housekeeping and Laundry verified the stained curtains, and the facility policy stated residents have the right to dignity, respect, and a safe, clean, comfortable, homelike environment.
Call Lights Not Within Reach of Residents: A resident who was bedbound had a hand bell placed above the bed and out of reach because the call light was not working, and the DON confirmed the resident could not reach it. Two other residents were observed with call lights on the floor under or behind the bed, and both said they did not know where the call light was. The facility policy stated call lights should be within easy reach when a resident is in bed or confined to a chair.
A facility failed to keep sharps and other potentially dangerous items out of resident rooms. In one room, a resident kept razors and large nail clippers in a dresser drawer, and in another, a resident had pointed scissors and a cigarette lighter on his table; the resident even stated the scissors were for stabbing. The DON confirmed residents should not have sharps or scissors in their rooms or possession.
The facility did not ensure that residents were protected from abuse, including physical, mental, and sexual abuse, physical punishment, and neglect by any person.
The facility did not manage its operations to ensure effective and efficient use of resources, as required by regulatory standards.
The facility did not set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action, resulting in a lack of systematic review and response to quality issues.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
The facility failed to store and prepare food in accordance with professional standards, with multiple instances of opened, undated, and unsealed food items, and kitchen equipment covered with food debris, grease, and grime. Despite having protocols and cleaning schedules, these were not effectively followed.
The facility failed to ensure the floors in hallways A, B, and C, as well as one resident room, were safe and free from accident hazards. Observations revealed raised floorboards and a missing area of floorboard, posing a tripping hazard. A family member reported tripping twice and stated that the issue had been reported to management without any corrective action being taken. The Director of Plant Operations confirmed the hazards during a tour and attributed the issue to old glue loosening and causing the floorboards to raise and separate.
A resident with Huntington's disease choked on a hotdog during lunch, requiring the Heimlich maneuver. The facility failed to notify the physician and the resident's family, and no follow-up for a swallowing disorder was conducted, despite the facility's policy requiring such notifications.
The facility failed to ensure a resident received necessary grooming services, as his fingernails were found to be dark yellow, elongated, and extended approximately 1/4 inch beyond the tip of each finger. Despite staff noticing the issue, no immediate action was taken to address it, contrary to the facility's policy on providing ADL care.
Failure to Enforce Smoking Policy and Control Smoking Materials for Oxygen‑Dependent Smokers
Penalty
Summary
Facility administration failed to ensure implementation of its Smoking/Vaping policy and adequate supervision for residents who smoked, including oxygen‑dependent residents, resulting in unsafe smoking practices and a serious injury. Staff, including CNAs and nursing leadership, were aware that multiple residents routinely retained cigarettes and lighters on their person or in their rooms and smoked in non‑designated areas, yet smoking materials were not consistently confiscated or controlled. During a tour, three residents were observed entering and leaving the designated smoking area with their own cigarettes and lighters, without obtaining them from or returning them to the supervising CNA, and then returning to rooms marked with “Oxygen in Use/No Smoking” signs while still in possession of smoking materials. One oxygen‑dependent resident with COPD, alcohol abuse, noncompliance with treatment, and intact cognition had a documented history of smoking in his room, including while on oxygen, dating back months before the incident. Nursing notes showed he was found smoking in his room on several occasions, including once while connected to his oxygen concentrator and another time with oxygen turned off, and he repeatedly refused to relinquish cigarettes and alcohol, becoming belligerent. Law enforcement was called at least once, and the DON and unit manager were notified, but there was no documentation that his smoking materials were consistently removed or that effective safeguards were put in place. His care plan addressed smoking and behaviors but did not include specific oxygen safety interventions, and he reported that he kept all smoking materials with him, smoked in his room and bathroom, and rarely saw staff in his room prior to the burn event. On the night of the burn incident, a CNA observed this resident smoking in his room while wearing a nasal cannula, saw the cannula ignite, and alerted an RN, who initiated a Code Red and emergency response. Documentation showed the resident sustained second‑degree burns to his nose and right cheek, experienced respiratory distress and other symptoms, and required transfer to an ED and then a burn unit, where he was intubated and treated for facial and inhalation burns. Other residents, including two additional oxygen‑dependent smokers and a non‑oxygen‑dependent smoker, reported that they routinely kept cigarettes and lighters on their person, sometimes smoked in their rooms or bathrooms, and did not trust staff to store their supplies. Smoking evaluations and care plans for these residents labeled them as safe smokers, often without supervision, and progress notes lacked documentation of noncompliance despite resident statements and staff interviews confirming ongoing violations of the smoking policy. A CNA reported that most smokers refused to surrender supplies, that leadership had long been aware of this pattern, and that staff training on smoking and oxygen safety was limited to self‑study folders without formal instruction or verification of understanding. Immediate Jeopardy at scope and severity level L was identified related to these failures, beginning on the date of the burn incident and remaining in effect through the survey exit. The IJ was based on the administration’s failure to ensure that staff, including CNAs, RNs, and the DON, enforced the smoking policy, removed smoking materials from oxygen‑dependent residents’ rooms, and prevented residents from smoking in their rooms while oxygen was in use. The facility also did not timely implement an effective, facility‑wide corrective approach to address systemic issues in smoking risk assessment, supervision, and environmental safety controls, allowing residents to continue to possess smoking materials and smoke inside the building and in non‑designated areas.
Failure to Use QAPI and Adverse Event Data to Control Unsafe Smoking and Oxygen Use
Penalty
Summary
The deficiency involves the facility’s failure to operate an effective QAPI process that used adverse event and safety data related to smoking and oxygen use to identify root causes and implement performance improvement activities. Despite a known pattern of residents retaining cigarettes and lighters on their person or in their rooms, including oxygen‑dependent residents, the facility did not ensure that smoking materials were controlled or that unsafe smoking behaviors were addressed. Staff and leadership were aware that multiple residents routinely violated the smoking policy, yet there was no effective system to analyze these events or modify care plans, supervision, or practices to prevent recurrence. One resident with COPD, chronic oxygen use, alcohol abuse, and documented noncompliance had a history of smoking in his room while on oxygen. Nursing notes showed he had been found smoking in his room on multiple prior occasions, including once while connected to his oxygen concentrator and another time with his oxygen turned off, and he refused to relinquish cigarettes and alcohol. Law enforcement had been called previously, and the DON and unit manager were notified of his behavior. His care plan addressed smoking and behavior but did not include oxygen safety interventions, and he continued to keep smoking materials on his person. On the night of the incident, he again smoked in his room while using oxygen, his nasal cannula ignited, and he sustained second‑degree facial burns and respiratory distress requiring emergent transfer to a hospital burn unit. Three other cognitively intact residents who smoked were also known to keep cigarettes and lighters on their person or in their rooms, including two who used oxygen. These residents reported that they routinely concealed smoking materials due to fear of theft, admitted to smoking in their rooms or bathrooms in violation of policy, and stated that staff rarely rounded in their rooms. Care plans and smoking evaluations documented them as safe smokers, often without supervision, and progress notes lacked documentation of noncompliance despite their own reports and staff observations. During surveyor observation, residents entered and exited the designated smoking area with their own cigarettes and lighters without surrendering them to staff, and oxygen‑in‑use/no‑smoking signs were posted outside their rooms. CNAs reported that most smokers refused to give up cigarettes and lighters and that they had repeatedly informed the unit manager, ADON, DON, and Administrator about residents smoking in rooms, including oxygen‑dependent residents, without effective follow‑up. Staff stated they did not attempt to confiscate smoking materials from certain residents due to prior aggression and that leadership did not change practices despite ongoing violations. Staff education on smoking and oxygen safety was described as limited to reading folders and signing sheets, with no formal in‑person training or verification of understanding. The facility had 45 smokers at the time of survey, and Immediate Jeopardy at a widespread level was identified related to the failure to use adverse event and safety information within QAPI to prevent recurrence of serious smoking‑ and oxygen‑related incidents.
Failure to Enforce Smoking Policy for Oxygen‑Dependent Smokers Resulting in Facial Burns and Immediate Jeopardy
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not enforcing its Smoking/Vaping policy for residents who smoked, including those who were oxygen‑dependent. Four residents who smoked and used or lived with oxygen were allowed to keep cigarettes and lighters on their person or in their rooms, and two oxygen‑dependent residents repeatedly smoked in their rooms, including while oxygen was in use. Staff, including CNAs, an RN, and the DON, were aware of ongoing unsafe smoking behaviors but did not consistently confiscate smoking materials, did not ensure materials were stored in the designated locked cart, and did not provide adequate supervision or rounding to prevent in‑room smoking. During a tour, surveyors observed three residents entering and leaving the designated smoking area with their own cigarettes and lighters, returning to rooms marked with “Oxygen in Use/No Smoking” signs without surrendering smoking supplies. One oxygen‑dependent resident with COPD, alcohol abuse, noncompliance with treatment, anxiety, and mood disorder had a history of smoking in his room while on oxygen, documented in multiple nursing notes over several months. On one earlier occasion, staff found him smoking with his nasal cannula on and oxygen flowing, with multiple beer cans in the room; he refused to relinquish cigarettes and alcohol, became belligerent, and law enforcement was called, but there was no documentation that staff removed his smoking materials. Another note documented him smoking in his room with oxygen turned off, with education provided and the DON notified, but again no successful confiscation of supplies. Despite care plan interventions requiring supervision while smoking and immediate notification of nursing staff if policy violations were suspected, he continued to keep all smoking materials with him, admitted to smoking in his room and bathroom, and reported that staff rarely entered his room. On the night of the burn incident, this same resident smoked in his room while receiving continuous oxygen at 2 L/min via nasal cannula. A CNA observed his nasal cannula ignite while he was smoking, and staff found burning oxygen tubing, a cigarette on the floor, and smoke in the room, triggering a Code Red and emergency transfer. Hospital records documented superficial partial‑thickness facial burns, soot in the nares and oropharynx, concern for inhalation injury, and the need for intubation during transport. Another oxygen‑dependent smoker, his roommate, reported that this resident smoked in the room multiple times a day while wearing oxygen and that he himself had also smoked in his own room, keeping cigarettes and a lighter on his person and not informing staff after obtaining supplies on leave of absence. Two additional residents, one oxygen‑dependent and one non‑oxygen‑dependent, also admitted to keeping cigarettes and lighters on their person, refusing to surrender them due to fear of theft, and acknowledged they were violating the smoking policy. Staff interviews confirmed that residents routinely refused to relinquish smoking materials and that CNAs and nurses often did not attempt to confiscate cigarettes and lighters from residents known to be aggressive, instead only notifying the Unit Manager, ADON, or DON. One CNA supervising the smoking area stated that most smokers kept their supplies on their person or in their rooms, that leadership had long been aware of this, and that no effective corrective action had been taken. Another CNA reported seeing an oxygen‑dependent resident smoking in his bathroom on the morning of the survey and only notifying the Unit Manager, without attempting to remove the smoking materials due to prior threats of aggression. Residents and staff both reported that nursing rounds were infrequent, with some residents stating they saw staff only a few times per day, allowing residents to smoke inside their rooms and bathrooms without detection. Documentation in care plans and smoking evaluations showed that residents were repeatedly classified as safe smokers, often without supervision, and that there was no recorded evidence of noncompliance with the smoking policy for several residents despite their own admissions and staff observations of in‑room smoking and retention of smoking materials. The facility’s failure to implement its Smoking/Vaping policy as written, to enforce storage of smoking materials in a locked cart, to reassess and document unsafe smoking behaviors, and to provide sufficient supervision and rounding for oxygen‑dependent smokers resulted in an Immediate Jeopardy situation. This failure directly contributed to the event in which an oxygen‑dependent resident’s nasal cannula ignited while he smoked in his room, causing second‑degree facial burns and respiratory distress requiring emergency transfer and burn‑unit care. The ongoing practice of allowing residents, including oxygen‑dependent residents and roommates of oxygen‑dependent residents, to retain cigarettes and lighters and to smoke inside the building left all residents at continued risk for serious injury, harm, impairment, or death, as explicitly stated in the report.
Failure to Enforce Smoking Policy and Supervise Oxygen‑Dependent Smokers Resulting in Facial Burns
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free of accident hazards and to provide adequate supervision and safeguards for residents who smoke, particularly those on oxygen. The facility had a Smoking/Vaping policy requiring smoking only in a designated area, storage of cigarettes and lighters in a locked cart, and use of smoking evaluations and care plans, but staff did not consistently implement these requirements. During a tour, three residents assigned to rooms with “Oxygen in Use/No Smoking” signs were observed entering and leaving the designated smoking area with their own cigarettes and lighters, without obtaining or surrendering smoking materials to the supervising CNA. These residents routinely kept cigarettes and lighters on their person or in their rooms, contrary to policy, and staff did not enforce the requirement to store smoking materials in the locked cart. One oxygen‑dependent resident with COPD, alcohol abuse, noncompliance with treatment, and intact cognition had continuous oxygen at 2 LPM via nasal cannula and a care plan addressing smoking and behavior, including a goal not to smoke without supervision. Despite this, multiple nursing notes documented that he had been found smoking in his room on several dates, including the day of the incident. On the day of the burn event, an RN observed him smoking in his bathroom around midday but did not retrieve cigarettes or a lighter, only notifying the DON. That night, a CNA entered the room to care for the roommate, smelled smoke, and saw the resident smoking in his room when his nasal cannula ignited. The CNA called the nurse, a Code Red was paged, and 911 was called. The resident sustained second‑degree burns to his nose and cheek, respiratory distress, and required emergency transfer, intubation, and burn‑unit care. The CNA later stated she had seen this resident smoking in his room about six times during the week of the event, had reported this to the DON, but did not confiscate his smoking supplies due to his aggressive behavior. Other residents confirmed ongoing noncompliance with the smoking policy and lack of effective supervision. An oxygen‑dependent resident who used oxygen mostly at night stated he always kept his cigarettes and lighter on his person, intentionally did not disclose them to staff after LOAs, and admitted to smoking in his room bathroom in the past, though he reported not using oxygen while smoking there. Another oxygen‑dependent resident reported she kept cigarettes and a lighter in her purse, did not trust staff to store them, and acknowledged knowing she was violating the policy, while stating she only smoked on the porch and not while on oxygen. A non‑oxygen‑dependent smoker, who had been the roommate of the burned resident and was the current roommate of another oxygen‑dependent smoker, stated that both roommates smoked in the room and bathroom, that one smoked while wearing oxygen, and that he himself kept multiple packs of cigarettes and a lighter in his pockets. Multiple residents reported that nursing staff came into their rooms infrequently, often only a few times per day, and that residents continued to smoke inside every day despite education. Staff interviews further demonstrated failures in supervision, enforcement, and follow‑through. CNA B reported that resident rounding was not consistently done every two hours due to workload and that there was limited supervision, with no new measures implemented to prevent oxygen‑dependent residents from smoking inside after the burn incident. LPN C stated there had always been a problem with residents hiding cigarettes and lighters and smoking in their rooms, and that she had been told that two residents smoked in their bathroom, but she was not aware of any new interventions to address this. RN E acknowledged personally witnessing the burned resident smoking in his room earlier on the day of the incident and knowing of prior episodes, but she did not secure his smoking materials. The DON stated he was aware that the burned resident had been caught smoking in his room multiple times and had received repeated education and written notices. Despite this knowledge, residents continued to retain smoking materials, smoke in non‑designated areas, and, in the case of two oxygen‑dependent residents, smoke in their rooms, leading to one resident’s facial burns and respiratory compromise and leaving all residents at continued risk for serious injury, harm, impairment, or death. Immediate Jeopardy at scope and severity K was identified, beginning on the date of the burn incident and remaining ongoing at survey exit. The facility’s documentation and assessments did not align with observed and reported behaviors. Care plans for the smokers included interventions such as keeping smoking products in a locked cart, explaining the smoking policy, and notifying the charge nurse if policy violations were suspected, but these interventions were not effectively implemented. Smoking evaluations repeatedly deemed several residents to be “safe smokers” who did not require supervision, despite their admitted and observed noncompliance with the policy and, for some, oxygen dependence. For one resident, the first smoking evaluation was not completed until months after admission and after the serious smoking‑related incident involving his roommate. Progress notes and scanned records lacked documentation of noncompliance for several residents, even though residents and staff described repeated violations. Staff also reported that post‑incident education largely consisted of reading materials and sign‑in sheets, with little or no formal, focused training on smoking safety and oxygen‑therapy safety, and they did not believe the training provided had been effective.
Failure to Report Adverse Incident Involving Oxygen‑Related Burn Injury
Penalty
Summary
The deficiency involves the facility’s failure to timely report an adverse incident to the Agency for Health Care Administration (AHCA) as required by its own Adverse Incident Reporting policy and Florida Statute 400.147. A cognitively intact resident with COPD on oxygen via nasal cannula, alcohol abuse, noncompliance with medical treatment, difficulty walking, dysphagia, anxiety disorder, and mood disorder smoked a cigarette in his room while receiving oxygen. The nasal cannula ignited, causing second‑degree burns to his face and respiratory distress. Staff responded to the fire alarm, turned off the oxygen, assessed the resident, and called 911; EMS and the fire department responded, and the resident was ultimately transported to an acute care hospital and accepted by a trauma/burn team. The resident’s hospital records documented superficial partial‑thickness facial burns, concern for inhalation injury, intubation during transport for airway protection, and soot in the nares and oropharynx. The facility’s own Ad Hoc QAPI meeting form dated the day of the incident described the event as the resident smoking in the room with oxygen in place and sustaining second‑degree burns on the face. The facility’s policy defined an adverse incident, in part, as any condition requiring transfer to a more acute level of care due to the incident rather than the resident’s prior condition, a criterion that was met when the resident was transferred to the hospital burn/trauma service. Despite this, the Administrator’s Reportable log for the month of the incident showed zero adverse incidents reported, and the Administrator confirmed there were none reported for that month. The Administrator, DON, and CEO each acknowledged in interviews that no adverse incident report was submitted to AHCA for this event. The Administrator stated she believed the incident should have been reported but did not submit a report after consulting with the Regional Clinical Consultant and CEO and because the annual state survey began shortly thereafter. The DON later confirmed, after reviewing the policy, that the incident should have been reported, and the CEO, upon reviewing the policy definition, agreed that the incident met the criteria for an adverse incident and that the facility failed to submit the required report.
Inaccurate PASRRs for residents with MDs/IDs
Penalty
Summary
The facility failed to provide accurate PASRRs for seven residents identified with mental disorders and/or intellectual disabilities and failed to ensure those residents were properly evaluated and received care and services in a setting appropriate for their needs. For Resident #23, the medical record showed diagnoses including generalized anxiety disorder, schizophrenia, brief psychotic disorder, major depressive disorder, and alcohol abuse, along with care plan concerns for impaired or inappropriate behaviors, trauma-related anxiety, and elopement risk; however, the PASRR dated 4/22/2025 did not identify any MDs and/or IDs. For Resident #62, the record showed dementia with behavioral disturbance, bipolar disorder, major depressive disorder, and anxiety disorder, with care plan focus areas for socially inappropriate behavior, verbal and physical aggression, obsessive behaviors, and elopement risk, yet the PASRR dated 3/11/2024 documented no MDs and/or IDs. Resident #63’s record included depression, psychosis, anxiety disorder, dementia with behavioral disturbance, major depressive disorder, and later documentation of frontotemporal neurocognitive disorder, dementia, mood disorder, and anxiety. Her care plan addressed behaviors such as eating paper and other non-food items, wandering and elopement risk, and delirium, but the PASRR dated 10/22/2024 did not document any MDs and/or IDs. Resident #65 had diagnoses including major depressive disorder, dementia, psychotic disturbance, mood disturbance, anxiety, and bipolar disorder, with care plan concerns for impaired or inappropriate behaviors, sexually inappropriate behaviors, sitting or crawling on the floor, noncompliance, and impaired cognitive function; the PASRR dated 8/24/2023 did not document the resident’s identified MDs or IDs. Resident #76’s diagnoses included bipolar disorder, dementia, psychotic disturbance, mood disturbance, anxiety, depression, and major depressive disorder, with care plan focus areas for disruptive sounds, impaired or inappropriate behaviors, ADL self-care deficits, little or no community life involvement, and behaviors involving disruptive sounds; the PASRR dated 11/2/2023 did not document any identified MDs or IDs. Resident #101 had diagnoses of schizoaffective disorder, bipolar type, alcohol abuse, major depressive disorder, anxiety disorder, and alcohol dependence, with care plan concerns for impaired or inappropriate behaviors, impaired cognition, verbal aggression, elopement risk, and impaired cognitive function related to alcohol abuse; the PASRR dated 8/22/2023 did not document the identified MDs/IDs. Resident #167’s record included depression, dementia with behavioral disturbance, bipolar disorder, major depressive disorder, anxiety disorder, and care plan concerns for anxiety and withdrawal, sexual behaviors and inappropriate sexual comments, refusal of medications, aggression toward staff, and elopement risk; the PASRR dated 5/28/2021 did not document the identified MDs/IDs. During interviews, the SSD stated she assisted with PASRRs, the DON usually completed them, and the forms were reviewed at admission and in morning meetings, with no additional audits. The DON stated the clinical team was responsible for ensuring all pertinent diagnoses were listed and that he used the hospital H&P to confirm MDs/IDs. On follow-up review, the DON compared the PASRRs with the electronic medical record for each of the seven residents and confirmed the PASRRs were inaccurate because diagnoses had been excluded. The facility policy stated that a Level II PASSR must be completed for individuals with dementia or suspicion/diagnosis of serious mental illness or intellectual disability, and that mental illness diagnoses added after admission should have a Level II PASSR completed again.
Failure to Provide Basic Grooming and Nail Care
Penalty
Summary
The facility failed to ensure that multiple residents received appropriate ADL care necessary to maintain good grooming, including clean, trimmed fingernails, shampooed hair, and removal of facial hair. Survey observations and interviews showed that residents had visibly overgrown, jagged, thickened, or dirty fingernails, and one resident had oily, disheveled hair. Another resident had thick black hair along the chin that remained present across multiple observations. The report identified eight sampled residents affected by these grooming deficiencies. Resident #5, who had diagnoses including cerebral infarction, major depressive disorder, PTSD, PVD, pressure ulcers, and a history of left shoulder absence, was observed with oily, disheveled hair and visibly stained, uneven, jagged fingernails with debris underneath them. He stated he did not know when he last received a shower or complete bed bath, said he had not received a shower for quite some time, and expressed that he wanted a real shower. His record showed he was dependent for bathing, personal hygiene, dressing, oral hygiene, and toilet hygiene, and the care plan identified a bathing preference for bed baths. Facility staff confirmed he was supposed to receive baths and that no baths had been documented since early February. Resident #34 was observed on multiple occasions with thick black hair along her chin while sitting in common areas and in bed. Staff stated she received showers routinely, but the shower documentation provided did not show any specific services such as shaving, and the LPN could not state when she was last shaved. Residents #11, #166, #91, #19, #82, and #159 were each observed with elongated fingernails, brown matter under the nails, or thickened and overgrown nails extending well beyond the nailbed. Several of these residents stated staff had not offered fingernail care or that nobody was doing nails, and staff interviews confirmed that nursing staff were responsible for grooming and nail care and that residents with long or soiled nails should receive assistance. The records for these residents showed varying levels of cognitive impairment and dependence or assistance needs for personal hygiene, bathing, and grooming, with care plans identifying ADL deficits and assistance needs.
Unqualified Full-Time Social Worker
Penalty
Summary
The facility failed to ensure that the full-time social worker was qualified and failed to verify that educational requirements were met in a facility licensed for 180 beds. During review of the Social Services Director’s personnel record, it was found that she did not have a bachelor’s degree in social work or a similar human services field. In an interview, the Administrator stated that she had concerns about the SSD’s performance and, after the SSD was promoted, requested copies of her master’s degree in social work, transcripts, and social worker license, but these documents were never provided. The Administrator also reported that during the recertification survey she asked the SSD to go home and obtain her degree and credentials, and by the end of the survey the SSD had not returned to the facility or contacted her.
Lack of bedside lighting in resident room
Penalty
Summary
The facility failed to ensure that one resident was provided adequate and comfortable lighting at the bedside. On 03/03/26, the resident was observed resting in bed in room [ROOM NUMBER], Bed D, and that area of the room was dark without a light source. The resident stated he did not know why he did not have a light in his area and that it bothered him that it was so dark. His roommate in Bed C stated he had previously been in Bed D but asked to move to Bed C so he would have a working light fixture over the bed. Beds A, B, and C in the room had wall-mounted light fixtures, but Bed D did not. The resident had been admitted on 01/22/26 with diagnoses including unsteadiness on feet, generalized muscle weakness, other reduced mobility, absence of the left leg below the knee, and absence of the right leg above the knee. His MDS assessment dated 01/28/26 showed a BIMS score of 11, indicating moderate cognitive impairment, and he required substantial to total assistance with multiple ADLs and transfers. His care plan identified an ADL performance deficit related to bilateral amputee status, cognitive issues, and need for assistance with daily care tasks. During interview, the Director of Housekeeping and Laundry verified that Bedroom [ROOM NUMBER], Bed D had no light fixture and stated she had not reported it to Maintenance. The facility's Resident Rights Policy and Dignity Policy stated residents have the right to a safe, clean, comfortable, homelike environment and to be treated with dignity and respect.
Incorrect Oxygen Flow Rates for Two Residents
Penalty
Summary
The facility failed to ensure that two residents who had physician orders for oxygen therapy received oxygen at the prescribed flow rates. Resident #54, who had a diagnosis of chronic obstructive pulmonary disease and an order dated 10/17/2025 for oxygen at 2 liters per minute via nasal cannula, was observed on 3/3/2026 and again on 3/4/2026 with the oxygen concentrator set at 2.5 liters per minute. During interview, an RN stated she checked oxygen concentrator settings when she arrived, acknowledged the resident should have been at 2 liters per minute, and then adjusted the flow rate from 2.5 to 2.0 liters per minute after checking the setting in the resident's room. Resident #49, admitted with diagnoses including wheezing, HIV disease, myocardial infarction, and COPD with acute exacerbation, had a physician order for oxygen at 2.0 liters per minute as needed. The resident, who had a BIMS score of 14 out of 15 and was documented as cognitively intact and independent with ADLs, was observed wearing a nasal cannula attached to an oxygen concentrator set at 5 liters per minute on two separate occasions. The resident stated they did not touch the oxygen flow rate settings. An LPN later checked the concentrator, confirmed it was set all the way to five, reviewed the medical record, and identified the order for oxygen at 2 liters per minute as needed. The facility's policy stated oxygen should be administered at the proper flow rate and medications should be given as prescribed.
Missing and Stained Privacy Curtains
Penalty
Summary
The facility failed to ensure privacy curtains were provided for five residents whose bedrooms lacked a privacy curtain track and privacy curtain. On observation, Resident #82 was seen in a bedroom without a privacy curtain track or curtain, and later Resident #192, Resident #5, Resident #116, and Resident #105 were also observed in bedrooms that lacked a privacy curtain track and privacy curtain. Photographic evidence was obtained during these observations. The facility also failed to ensure privacy curtains were not stained for two beds in one resident room. Curtains for beds 9B and 9D were observed to be heavily stained, including black scratch marks on the lower portion of one curtain and large dark spots on the upper right portion of the other. These conditions were observed on two separate occasions, and the Director of Housekeeping and Laundry verified that the curtains were heavily stained. The facility's Resident Rights Policy stated that each resident has the right to be treated with dignity and respect and to have a safe, clean, comfortable, homelike environment.
Call Lights Not Within Reach of Residents
Penalty
Summary
A working call system was not available within easy reach for three residents. Resident #13 was observed lying in bed with a hand bell placed on top of the light above the head of the bed, approximately 3.5 feet above the bed and not within reach. The resident did not respond to questions about the hand bell, and the roommate stated the resident could not talk and had been given the hand bell because the call light was not working. The DON later confirmed the resident was bedbound and would not be capable of reaching above the bed to retrieve the hand bell. Resident #43 was observed resting in his room with the call light on the floor under the bed frame at the head of the bed, and on a later observation it was still in the same location. Resident #149 was also observed resting in his room with the call light on the floor behind the head of the bed, and on a later observation it remained there. Both residents stated they did not know where the call light was. The facility's Call Light Policy stated that when a resident is in bed or confined to a chair, the call light should be within easy reach of the resident.
Sharps and other dangerous items left in resident rooms
Penalty
Summary
The facility failed to provide a safe environment for two residents by allowing sharp and potentially dangerous items to remain in resident rooms. In a secured Memory Care Unit room shared by two residents, an open dresser drawer contained a clear plastic bag with several blue razors and large nail clippers. On a later tour, the bag was still in the drawer, and one resident confirmed the dresser and the items were his. A RN then observed the contents of the open drawer, removed the bag, and confirmed that the resident should not have had those items in his possession and that residents were not permitted to have those kinds of items in their rooms. A second resident had a pair of adult comfort grip scissors with a pointed tip observed on his table while he was sitting in his wheelchair preparing to eat lunch, and he stated, "To stab you with them." On later observations, the same scissors and a cigarette lighter were again seen on his table when he was not in the room. The DON confirmed that no resident should have sharps or scissors in their room or possession at any time. A CNA later acknowledged that the resident was not permitted to have the cigarette lighter and scissors in his room and stated that such items should be removed, the nurse notified, and the incident documented.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from all forms of abuse, including physical, mental, and sexual abuse, as well as physical punishment and neglect by any individual. This deficiency indicates that there was an incident or incidents where residents were not safeguarded from such mistreatment, as required by regulations. Specific details about the actions or inactions leading to the abuse or neglect, as well as information about the residents involved, are not provided in the report.
Ineffective Resource Management
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of its resources. This deficiency was identified based on observations and findings by surveyors, indicating that the facility did not meet the required standards for resource management as outlined in regulatory guidelines. No specific details regarding individual residents, staff actions, or particular events leading to this deficiency are provided in the report excerpt.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process for identifying, reviewing, and addressing quality issues within the facility. As a result, there was no documented evidence that quality deficiencies were being regularly reviewed or that corrective plans were being developed and implemented to address identified issues.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records, where it was noted that the care plan did not comprehensively cover the resident's needs as required.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details regarding specific residents, staff actions, or the circumstances leading to the deficiency are provided in the report.
Failure to Maintain Food Safety and Kitchen Cleanliness
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. Observations revealed multiple instances of opened, undated, and unsealed food items in the kitchen's dry storage area, walk-in refrigerator, and reach-in freezer. Specific items included an open, undated bag of potato chips, penne pasta noodles, Classic [NAME] Quick Grits mix, wheat bread, battered fish, canned pineapple, shredded lettuce, iceberg lettuce heads, chopped green peppers, chicken thighs, frozen biscuits, and tortillas. Additionally, the kitchen equipment, including the cooktop, stove, and ovens, were found covered with food debris, grease, and grime, despite a cleaning schedule being in place. Photographic evidence was obtained to support these findings. Interviews with the Certified Dietary Manager (CDM) revealed that the facility had protocols and cleaning schedules in place, but these were not being effectively followed. The CDM explained that both she and the kitchen supervisor were responsible for checking the daily cleaning schedule and ensuring that staff completed their assigned tasks. However, the observations indicated that these protocols were not being adhered to, as evidenced by the condition of the kitchen equipment and the improper storage of food items. The facility's policies on labeling, dating, and sealing opened food, as well as maintaining kitchen cleanliness, were not being followed, leading to the identified deficiencies.
Facility Failed to Address Flooring Hazards
Penalty
Summary
The facility failed to ensure the floors in hallways A, B, and C, as well as one resident room, were safe and free from accident hazards. Observations revealed raised floorboards and a missing area of floorboard in these areas, posing a tripping hazard. A family member reported tripping twice due to the raised flooring and stated that the issue had been reported to management without any corrective action being taken. The Director of Plant Operations confirmed the presence of the hazards during a tour of the facility and attributed the issue to old glue loosening and causing the floorboards to raise and separate. The Environmental Performance Improvement Plan, which began in March 2024, focused on the age of the building, housekeeping, and timely completion of work orders. However, a review of recent Angel rounds did not acknowledge the flooring hazards, with most comments only addressing soiled floors. The Maintenance Service Policy and Procedure, dated April 2022, mandates maintaining the building in good repair and free from hazards, but this was not adhered to in the case of the flooring issues in the hallways and resident room.
Failure to Notify Physician and Family After Choking Incident
Penalty
Summary
The facility failed to notify the physician for a resident after she choked during a lunch meal in her room. The incident occurred when the resident, who has Huntington's disease and severe cognitive impairment, took three large bites of a hotdog and began choking. A Licensed Practical Nurse (LPN) performed the Heimlich maneuver, successfully clearing the resident's airway. However, the physician and the resident's family were not notified of the incident as required by the facility's policy and procedure for changes in a resident's condition or status. The resident's medical record did not indicate any notification to the physician or family, nor was there an order for a Speech Therapy (ST) evaluation or screening following the choking incident. The resident's care plan did not include any measures related to swallowing difficulties, despite the resident's diagnosis of Huntington's disease, which can lead to such issues. Interviews with the facility staff, including the LPN, Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Speech Therapist (ST), revealed that none of them were aware of the choking incident or had taken steps to address the resident's swallowing difficulties. The primary care physician and the Advance Practice Nurse Practitioner (APRN) confirmed that they had not been contacted regarding the choking incident. The facility's policy requires prompt notification of the physician and the resident's representative in the event of significant changes in the resident's condition. The failure to notify the physician and the resident's family, as well as the lack of follow-up for a potential swallowing disorder, constitutes a deficiency in the facility's care for the resident.
Failure to Maintain Resident's Grooming
Penalty
Summary
The facility failed to ensure that a resident received necessary services to maintain good grooming, specifically by not trimming or clipping his fingernails. On two separate observations, the resident's fingernails were found to be dark yellow, elongated, and extended approximately 1/4 inch beyond the tip of each finger. The resident expressed dissatisfaction with the length of his fingernails. The resident had been admitted with diagnoses including monoplegia of the upper limb, hemiplegia, hemiparesis, hyperlipemia, pain, and hypertension, and required assistance with personal hygiene due to an ADL deficit in self-care performance. Interviews with facility staff revealed that both CNAs and nurses were responsible for clipping and filing residents' fingernails. However, there was a lack of clarity on where to document this assistance. The CNA assigned to the resident noticed the long fingernails but had not yet addressed the issue. Similarly, the RN noticed the long fingernails while administering medications but had not taken immediate action. The facility's policy emphasized the importance of providing care and services for activities of daily living, including grooming, but this was not adequately followed in the case of this resident.
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Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
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