Alhambra Healthcare & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Petersburg, Florida.
- Location
- 7501 38th Ave N, Saint Petersburg, Florida 33710
- CMS Provider Number
- 105712
- Inspections on file
- 23
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Alhambra Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to ensure that LPNs administering IV antibiotics, including through PICC lines, had the required IV therapy certification and documented competency. Several residents with wound infections and osteomyelitis had physician orders for IV Vancomycin, Cefepime, and Cefazolin, and MARs showed multiple IV doses documented by various LPNs whose IV certification status was either unknown, not provided, or explicitly lacking. Interviews confirmed that some LPNs were not IV certified or could not produce certificates, the ADON did not hold IV certification in the state, and the DON had to administer at least one IV antibiotic dose. In addition, one resident did not receive a scheduled morning dose of IV Cefazolin, despite a later dose already being scheduled.
Surveyors found that staff failed to follow infection prevention and control practices for multiple residents, including those on Enhanced Barrier Precautions and those with a PICC line and nebulizer treatments. A resident on Enhanced Barrier Precautions had trash receptacles in the room and bathroom without liners, including overflowing containers full of used gloves and isolation gowns placed near a roommate’s bed, and dirty linen was left on a chair with a blanket removed from the soiled pile to be reused. During care for this resident, a CNA provided care without wearing a required gown despite isolation signage. Another resident receiving nebulizer treatments and IV antibiotics via a PICC line had an exposed nebulizer mask and an opened saline flush left on a dirty nightstand, and the PICC dressing was not changed within the facility’s stated seven-day interval. A shared trash receptacle for this resident and a roommate was also placed under the resident’s wheelchair with PPE hanging over the edge, contrary to the facility’s written standard precautions policy.
A resident admitted from the hospital with multiple documented pressure injuries to the sacrum, buttocks, and gluteal folds did not receive timely and appropriate wound treatment. Admission records and physician orders required daily monitoring and every-shift skin observations but contained no specific wound care treatment orders, and nursing staff did not obtain such orders. During a skin assessment, the DON and an RN found a large open area with a dark center on the lower back and additional open areas on the lower buttocks/upper thighs, with drainage noted on the incontinence brief and no dressings in place despite the resident having arrived with dressings. The RN could not explain the absence of dressings, and the wound NP reported she had not been contacted to see the new admit sooner or to provide interim treatment guidance, contrary to the facility’s wound management policy requiring evidence-based treatments and physician-directed wound care.
Two residents with significant mobility and toileting needs did not consistently receive timely assistance with toileting and incontinence care, as documented in their care plans. Documentation and interviews revealed that staff often provided assistance only once per day or not at all during some shifts, and residents reported long waits for help, particularly at night.
A resident admitted with severe post-surgical pain did not receive prescribed hydrocodone in a timely manner due to delays in medication procurement and lack of documented efforts by staff. Additionally, discrepancies were found between the Medication Administration Record and the controlled substance log, with several doses not properly documented. Facility staff confirmed the lack of a clear policy for timely medication delivery and acknowledged inconsistencies in recordkeeping.
Surveyors found that multiple resident rooms and bathrooms were not maintained in a safe or sanitary condition, with issues such as missing caulking around commodes, soiled and discolored flooring, and stained privacy curtains. The Maintenance Director reported being behind on work orders, contributing to the ongoing deficiencies.
Two residents experienced ant infestations in their rooms, with ants observed near food debris and on a bathroom windowsill. Despite prior complaints and facility policy requiring documentation and prompt action, staff did not log the pest sightings or ensure targeted treatment, resulting in ongoing pest issues.
The facility did not document required notifications for room changes involving three residents. Record reviews and interviews confirmed that notifications and reasons for the room changes were not entered in the progress notes, as required by policy. The DON acknowledged the missing documentation and confirmed that the process for notifying residents and their representatives was not consistently followed.
Surveyors found that multiple medication carts contained undated and improperly labeled medications, including eye drops, inhalers, and oral medications. LPNs interviewed were inconsistent in their labeling practices, and some were unfamiliar with facility procedures. The DON confirmed that all medications should be labeled with the date opened and expiration date, as required by facility policy, but this was not consistently done.
The facility was found deficient in its Emergency Preparedness Program for failing to include procedures for sewage and waste disposal for all 56 residents. This was identified during a record review with the Maintenance Director and Regional Maintenance Consultant, who acknowledged the absence of such procedures. The issue was discussed with the facility's administration during an exit conference.
The facility failed to maintain its generator according to NFPA standards, lacking evidence of weekly inspections and monthly load testing prior to February 2025. This deficiency was acknowledged by the Maintenance Director and discussed during an exit conference.
The facility failed to maintain an exit door in the 100-wing corridor, as it had a sign stating "*DO NOT EXIT" "ALARM WILL SOUND!" and did not close and latch properly. This was observed during a tour with the Maintenance Director and Regional Maintenance Consultant, and acknowledged during an interview and exit conference. Photographic evidence was obtained, and the deficiency is cited under NFPA 101 standards.
The facility failed to maintain its commercial cooking hood and fire suppression system according to NFPA standards. It did not provide evidence of one required semi-annual fire suppression inspection for 2024 and lacked regular monthly kitchen quick check inspections. Additionally, the cooking hood was not grease-tight due to unsealed seams. These issues were acknowledged by the facility's maintenance staff and discussed during the exit conference.
The facility failed to comply with NFPA 101 standards for the installation of alcohol-based hand rub (ABHR) dispensers. During a facility tour, it was found that dispensers in the employee lounge and corridor were installed within one inch of ignition sources, such as light switches and receptacles. These findings were acknowledged by the Maintenance Director and reviewed with the facility's administration.
The facility failed to maintain two duct smoke detectors according to NFPA 101 standards. The required annual duct detector differential pressure testing was not conducted, with the last test dated over a year ago. Additionally, biennial sensitivity testing was not documented. These deficiencies were acknowledged by the Maintenance Director and discussed with the Administrator.
The facility failed to maintain its automatic fire sprinkler system according to NFPA 101 standards. A cable was improperly zip-tied to the fire sprinkler piping, and a sprinkler in the medical records storage room contained foreign material. These issues were identified during an inspection and acknowledged by the facility's maintenance staff.
The facility did not conduct fire drills as required by NFPA 101, failing to provide evidence for one drill in the third quarter and two drills in the fourth quarter of 2024 across various shifts. This was acknowledged by the Maintenance Director and discussed with the Administrator.
An oxygen cylinder in a transport cart was found unsecured during a facility tour, violating NFPA 99 standards. The Maintenance Director and Regional Maintenance Consultant acknowledged the deficiency, which was reviewed with the Administrator during the exit conference. Photographic evidence was obtained.
The facility did not post up-to-date nurse staffing information on one observed day. On that day, the posted information was outdated by two days, failing to meet the facility's policy of daily updates. The policy requires posting the facility name, current date, and staffing details for RNs, LPNs, and CNAs in a clear format accessible to residents and visitors.
The facility failed to maintain professional standards for food service safety, with issues in food storage, labeling, and cleanliness. Observations revealed improperly stored and labeled food items, including vegan bacon without a use-by date, spoiled produce, and moldy lemons and limes. The dish machine was found with crumbs and rust, and the dining room refrigerator contained unlabeled resident food. Interviews indicated that staff responsibilities for storage and labeling were not consistently followed, despite policy guidelines.
The facility did not comply with staffing standards by failing to update the nurse staffing information on the East Wing. Observations showed that the staffing board remained unchanged throughout the day, displaying only limited staff names without room numbers or shift data. This non-compliance with the facility's policy and state regulations hindered transparency and accessibility of staffing information for residents and the public.
The facility failed to complete Level II PASRR evaluations for several residents with serious mental illnesses and neurocognitive disorders, as required by guidelines. Despite indications from Level I screens, necessary evaluations were not conducted, and staff interviews revealed a lack of awareness about the requirement.
The facility did not maintain a safe and homelike environment in two resident rooms. In one room, a resident reported a broken armoire drawer, and in another, the toilet base was unsecured. Staff failed to place work orders for these issues, and the facility could not provide a maintenance policy. Photographic evidence was obtained.
The facility failed to develop individualized care plans for two residents, one with PTSD and another with end-stage renal disease. The care plans lacked specific interventions and updates, leading to deficiencies in addressing their needs. Staff were unaware of the PTSD triggers for one resident, and the dialysis care plan for the other was incomplete. The facility's policies emphasize comprehensive, person-centered care plans, but these were not met.
A facility failed to identify PTSD triggers and develop an individualized care plan for a resident with PTSD. The resident's care plan mentioned the risk of re-traumatization but lacked specific interventions. Staff interviews revealed a lack of awareness and training regarding PTSD triggers. The facility's policy emphasized culturally sensitive care, but implementation was lacking.
The facility did not ensure a safe, clean, and homelike environment in two resident rooms. In one room, a resident reported a broken armoire drawer, and in another, the toilet base was unsecured. Staff confirmed the issues, but no work orders were placed, and the facility lacked a maintenance policy.
Failure to Ensure LPN IV Certification and Proper Administration of IV Antibiotics
Penalty
Summary
The deficiency involves the facility’s failure to ensure that LPNs had the required IV therapy certification and documented competency to administer IV medications, including through PICC (a type of central venous catheter), for multiple residents. Florida Board of Nursing requirements cited in the report specify that LPNs may perform IV therapy only after appropriate education and training, including a minimum of four hours of instruction with didactic and clinical components, and facility-determined competency. Despite these requirements, several LPNs either lacked IV certification, had not provided proof of certification, or had incomplete documentation of their IV training while still being associated with residents receiving IV antibiotics. For one resident with an infected left foot and a PICC line, physician orders included Cefepime IV every 12 hours for several weeks and Vancomycin IV once daily. The MAR showed multiple IV antibiotic administrations documented by various LPNs, including entries by LPNs later identified as not IV certified or unable to produce IV certification (e.g., Staff B, C, E, J, L, and others). Interviews revealed that one LPN assigned to this resident stated she was new, had not provided her IV course certificate, and could not administer the ordered IV antibiotic; the ADON also stated she did not have an IV certificate in Florida and that the DON would administer the IV antibiotic. Another LPN reported she had taken an IV course a year prior but never received a certificate and would need to contact the organization that provided the course, despite having been employed at the facility for nearly a year. For another resident with wound infection requiring Vancomycin IV and a third resident with osteomyelitis requiring Cefazolin IV three times daily, physician orders and MARs showed multiple IV antibiotic administrations documented by LPNs whose IV certification status was not verified or was explicitly reported as lacking. The MAR for the resident with Vancomycin showed several IV doses signed out by different LPNs, and the MAR for the resident with Cefazolin showed numerous IV doses documented by multiple LPNs, including agency staff. During an interview, facility leadership confirmed that one resident had not received a scheduled morning dose of Cefazolin, even though the next dose was already scheduled for later that day. Overall, observations, interviews, and record review demonstrated that the facility did not ensure LPNs administering IV medications, including via PICC lines, were appropriately IV certified and that IV therapy was administered as ordered.
Infection Control Failures with PPE Use, Device Care, and Waste Handling
Penalty
Summary
Surveyors identified multiple failures in the facility’s infection prevention and control practices involving residents on Enhanced Barrier Precautions and those receiving respiratory treatments and IV therapy. For one resident on Enhanced Barrier Precautions due to a right nephrostomy and indwelling suprapubic catheter, surveyors observed small trash receptacles in the room and bathroom without disposable liners, including one receptacle containing used gloves, gowns, and other garbage. Later observations showed an overflowing trash receptacle without a liner, full of doffed gloves and isolation gowns, positioned near the roommate’s bed as the roommate and a family member entered the room. Dirty linen was also observed tossed on a chair, with a blanket removed from the soiled linen pile to be returned to the resident. During care for this same resident, an unidentified CNA provided care while the resident was on Enhanced Barrier Precautions but was not wearing a gown despite appropriate signage posted on the door. For another resident receiving respiratory treatments and IV antibiotics via a PICC line, surveyors observed an exposed nebulizer mask left out on a dirty nightstand surface, along with an opened normal saline flush that was not properly stored. The resident’s PICC line dressing was labeled with a date indicating it had not been changed within the facility-stated seven-day interval, and the DON acknowledged that the dressing should have been changed the previous day. After IV antibiotic administration and PICC dressing observation, the trash receptacle for this resident and the roommate was found placed in front of the resident’s footboard under the wheelchair, with PPE hanging over the edge. These observations occurred despite a facility policy on Standard Precautions Infection Control that requires appropriate PPE use, proper handling and disposal of contaminated equipment and materials, and staff training on infection prevention procedures.
Failure to Provide Timely Wound Treatment for Existing Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate treatment and services for existing pressure ulcers for one resident. The resident reported being admitted from the hospital with sores on his bottom and stated he had not received a bath or shower and could not recall if his wounds had been addressed. The admission documentation (3008 Section T and initial skin assessment dated 02/27/2026) identified multiple pressure wounds on the sacrum, bilateral buttocks, and gluteal folds with specific measurements. Physician orders dated 02/27/2026 included daily monitoring of the sacral wound with documentation of dressing presence and status, surrounding skin condition, possible complications, and pain, as well as every-shift skin observations and Enhanced Barrier Precautions. However, there were no physician orders for actual wound care treatments such as cleansing method, type of dressing, or frequency of dressing changes. During a head-to-toe skin assessment on 03/03/2026 with the DON, the resident was observed wearing incontinence briefs with small areas of drainage and no wound dressings present for removal. The DON observed a large open area on the lower back approximately palm-sized with a dark black area in the center, and small open areas on the left and right lower buttocks/upper thigh areas. The DON and an RN then cleansed the wounds with normal saline and applied large bordered dressings. The RN later stated she recalled the resident arriving with dressings in place but could not explain why there were no dressings at the time of the observation, and confirmed she is the designated nurse assisting the wound NP on weekly wound rounds. The wound NP reported she makes rounds weekly, relies on the facility to email new admits or readmits to be seen, had received no communication requesting an earlier visit or guidance for this resident, and understood she was to see the resident on her normal weekly rounds. The facility’s wound treatment management policy requires that wound treatments be provided per physician orders and that, in the absence of treatment orders, the licensed nurse notify the physician to obtain them, which did not occur for this resident’s pressure wounds.
Failure to Provide Consistent Toileting Assistance for Residents
Penalty
Summary
The facility failed to provide adequate care and services for activities of daily living, specifically toileting assistance, for two residents. One resident, admitted with peripheral vascular disease and chronic obstructive pulmonary disease, required assistance with ambulation and toileting due to recent arterial bypass surgery and significant pain. Despite care plans and assessments indicating the need for staff assistance with toileting and incontinence care, documentation showed inconsistent provision of these services. The resident reported being left in feces and urine for hours at night, and records indicated that toileting assistance was documented only once per day on several occasions, rather than at least once per shift as expected. Another resident, with diagnoses including heart failure and decreased mobility, also required hands-on assistance with toileting. Over a 29-day period, documentation revealed that toileting assistance was provided only 56 times across 87 shifts, with some days showing only one instance of assistance or none at all. The resident confirmed delays in staff response to call bells, sometimes waiting 30-40 minutes or not receiving assistance at all. Care plans for both residents included interventions for toileting and incontinence care, but the documented care did not align with these plans. Interviews with staff, including the Medical Records manager and the DON, confirmed the lack of consistent documentation and provision of toileting assistance. The DON acknowledged that records reflected toileting assistance being provided only once per day for one resident. These findings demonstrate a failure to ensure that residents received timely and adequate assistance with toileting and incontinence care as required by their care plans and clinical needs.
Failure to Ensure Timely Pain Medication Procurement and Accurate Controlled Substance Documentation
Penalty
Summary
The facility failed to ensure timely procurement of pain medication and accurate accounting of controlled substances for a resident admitted with significant pain following an arterial bypass surgery. Upon admission, the resident reported severe pain and was unable to walk due to surgical incisions with staples in place. Despite a physician's prescription for hydrocodone being signed prior to admission and faxed on the day after admission, there was no documentation of efforts by the facility to obtain the medication from the time of admission until more than 24 hours later, resulting in a delay in pain management. Review of the resident's records showed ongoing reports of moderate to severe pain, with pain levels frequently documented as 7 or higher on a 10-point scale. The Medication Administration Record (MAR) and the Medication Monitoring Control Record for hydrocodone did not match, with several instances where withdrawals of the medication were not documented on the MAR. The facility's policy required that the dose noted on the usage form or dispensing system must match the dose recorded on the MAR and controlled drug record, but this was not followed in this case. Interviews with facility staff, including the DON and pharmacy consultant, confirmed that medications for new admissions should be received by the next pharmacy delivery and that documentation should be consistent between records. However, the facility lacked a policy and procedure for timely medication procurement, and staff acknowledged the discrepancies between the MAR and control records. These failures resulted in both a delay in pain medication administration and inaccurate accounting of controlled substances for the resident.
Failure to Maintain Safe, Sanitary, and Comfortable Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, sanitary, and comfortable homelike environment in 6 out of 16 resident rooms inspected. Specific deficiencies included absent caulking around commodes, discoloration and uncleanliness on commodes, unclean and soiled flooring in resident rooms and bathrooms, and visible discoloration on privacy curtains. In several rooms, the commodes lacked proper caulking at the base, and the surrounding flooring was noted to be darker, sticky, or heavily soiled with various discolorations. One privacy curtain was observed to have a dark brownish-red discoloration in the shape of a T, along with additional spots. In another instance, the commode had brownish marks on the outside, heavy discoloration at the floor juncture, and dried reddish-brown matter under the toilet seat. Additionally, a detached corner molding was found laying on the hallway floor at the entrance to the 100 hall. During an interview, the Maintenance Director, who had been employed for seven weeks, stated he was still addressing work orders that predated his employment. The observations and interviews confirm that the facility did not ensure a consistently clean, safe, and comfortable environment for residents, staff, and the public in the areas inspected.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of ants in the rooms of two residents. During a facility tour, a line of tiny ants was observed crawling on the floor next to a resident's nightstand, where food debris was also present. The resident confirmed having seen ants on his bed. Another resident reported seeing ants in his bathroom by the window, and observation confirmed a line of ants just below the windowsill. The resident stated he had reported the issue previously, but the ants persisted. Interviews with facility staff revealed that the pest control company visits every other Friday and as needed, but complaints about bugs and a rodent in the attic had been ongoing. Review of pest control invoices showed recent treatments focused on exterior areas, kitchen, and common spaces, with no specific mention of ant treatment in the affected rooms. The Environmental Service Manager acknowledged receiving complaints about ants and observing them in a resident's room due to food on the floor, but did not document the sighting in the pest logbook as required by facility policy. The facility's pest control policy mandates maintaining a report system for pest issues between scheduled visits, which was not followed in this instance.
Failure to Document Resident Room Change Notifications
Penalty
Summary
The facility failed to document notifications of room changes for three residents, as required by resident rights regulations. Record reviews showed that one resident changed rooms multiple times, but notifications of these changes were not documented in the progress notes for several of the moves. Similarly, two other residents experienced room changes, and there was no documentation in their progress notes indicating that they or their representatives were notified of the changes or the reasons for them. The Director of Nursing (DON) confirmed during interviews that the Social Services Director (SSD) is responsible for notifying families and that nursing staff complete the transfers, but acknowledged that documentation of these notifications was missing for the affected residents. The facility's policy on resident rights, which includes the right to be informed about room changes, was not followed in these instances. The DON reviewed the records and confirmed the lack of documentation for the required notifications and reasons for the room changes. The absence of these records indicates that the facility did not consistently honor the residents' rights to receive written notice before a room change was made.
Failure to Properly Label and Store Medications in Medication Carts
Penalty
Summary
Surveyors observed that medications and biologicals in three medication carts were not labeled or stored according to facility policy and professional standards. Specifically, undated used bottles of Latanoprost eye drops, Breo inhalers, and a Combivent inhaler were found in one cart, with packaging indicating expiration periods after opening but lacking any opening dates. Another cart contained an opened bottle of Ibuprofen without an opening date, which was only labeled after the surveyor's observation. A third cart had an undated empty bottle of Omeprazole, undated used bottles of Latanoprost, Loteprednol, and Timolol eye drops, and an undated used Breo inhaler, again with no indication of when these medications were opened. Interviews with LPNs revealed a lack of consistent practice in labeling medications upon opening, and one LPN was unfamiliar with the facility's pharmacy procedures due to being new. The DON confirmed that all medications should be labeled with the date opened and expiration date, and acknowledged the presence of agency staff as a contributing factor. A review of facility policies showed clear requirements for labeling medications with opening and expiration dates, and for removing outdated or improperly labeled medications from inventory. The policies also specified that certain medications require a shorter expiration period once opened, and that any medication found without a date should default to the date dispensed. Despite these policies, the observed medication carts contained multiple items that were not labeled as required, indicating a failure to follow established procedures for medication labeling and storage.
Deficiency in Emergency Preparedness: Lack of Sewage and Waste Disposal Procedure
Penalty
Summary
The facility failed to incorporate procedures for sewage and waste disposal into their Emergency Preparedness Program (EPP) for all 56 residents. This deficiency was identified during a record review conducted with the Maintenance Director and the Regional Maintenance Consultant. The review took place on March 31, 2025, between 9:30 a.m. and 1:30 p.m. During this review, it was found that the facility did not have a procedure in place for sewage and waste disposal in the event of a system loss. An interview with the Maintenance Director and the Regional Maintenance Consultant confirmed the absence of this procedure. These findings were subsequently discussed with the Administrator, the Maintenance Director, and the Regional Maintenance Consultant during an exit conference held on the same day between 4:15 p.m. and 4:30 p.m. The lack of a sewage and waste disposal procedure is a violation of the Code of Federal Regulations, specifically 42 CFR § 483.73(b)(1)(D).
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the accuracy of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted to comply with the requirements set forth under state and federal laws and agencies. 1. The QA & A committee will review to approve the procedure for sewage and waste disposal on 4/24/2025. 2. No other areas or residents were affected by deficient practice. 3. Education provided to the Maintenance Director by NHA or designee on procedures for sewage and waste disposal by 4/24/2025. 4. All policies and procedures will be reviewed and monitored annually by the QA & A committee.
Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its generator in accordance with NFPA 99 and NFPA 101 standards. During a record review conducted with the Maintenance Director and the Regional Maintenance Consultant, it was found that the facility did not have evidence of weekly visual inspections of the generator prior to February 2025. Additionally, the facility lacked documentation of the monthly load testing of the generator for the same period. These deficiencies were acknowledged by the Maintenance Director and the Regional Maintenance Consultant during the review. The findings were discussed with the Administrator, the Maintenance Director, and the Regional Maintenance Consultant during an exit conference. The absence of records for the required inspections and testing indicates a failure to comply with the necessary maintenance and testing protocols as outlined in NFPA 99 and NFPA 101. This oversight could potentially impact the facility's ability to ensure the generator's readiness and reliability in providing essential power during emergencies.
Plan Of Correction
1. The Maintenance Director in charge of oversight of generator weekly and monthly testing in 2024 is no longer with the facility. The new Maintenance Director is in compliance with weekly and monthly testing of generator. 2. No other areas or residents were affected by deficient practice. 3. Education was provided to the Maintenance Director by NHA on 4/17/2025 on maintaining the generator in accordance with NFPA 99. 4. Results of the weekly and monthly generator testing will be reported to the QA&A committee and reviewed monthly.
Exit Door Deficiency in 100-Wing Corridor
Penalty
Summary
The facility failed to maintain one of two exits in the corridor of the 100-wing, as observed during a tour conducted by the Maintenance Director and the Regional Maintenance Consultant. The exit door located by resident room 102 had a sign posted on it stating "*DO NOT EXIT" "ALARM WILL SOUND!" Additionally, the exit door did not close and latch properly when tested, which is a violation of the NFPA 101 Life Safety Code requirements. These findings were acknowledged by the Maintenance Director and the Regional Maintenance Consultant during an interview conducted concurrently with the record review. The deficiency was further discussed with the Administrator, the Maintenance Director, and the Regional Maintenance Consultant during the exit conference. Photographic evidence was obtained to document the deficiency, which is cited under NFPA 101 (2012 and 2021 Editions) sections 19.2.1, 19.2.2.2, 7.1.10.1, 7.1.10.2.1, and 7.2.1.4.5.
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the accuracy of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted to comply with the requirements set forth under state and federal laws and agencies. 1. The sign was removed from the exit door on 3/31/2025 located by resident room 102 by maintenance staff. The door that failed to latch was repaired by Regional Maintenance Consultant on 3/31/2025 and the door now closes and latches appropriately. 2. Exit doors in facility were audited for removal of any do not exit signs and to ensure doors close and latch by Maintenance Director on 04/01/2025. 3. Education was provided to the Maintenance Director on Means of Egress Requirements. The Maintenance Director or designee will conduct quality assurance checks weekly for 12 weeks ensuring no exit signs on exit doors and doors closing and latching appropriately. 4. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured. Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the accuracy of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted to comply with the requirements set forth under state and federal laws and agencies. 1. The sign was removed from the exit door on 3/31/2025 located by resident room 102 by maintenance staff. The door that failed to latch was repaired by Regional Maintenance Consultant on 3/31/2025 and the door now closes and latches appropriately. 2. Exit doors in facility were audited for removal of any do not exit signs and to ensure doors close and latch by Maintenance Director on 04/01/2025. 3. Education was provided to the Maintenance Director on Means of Egress Requirements. The Maintenance Director or designee will conduct quality assurance checks weekly for 12 weeks ensuring no exit signs on exit doors and doors closing and latching appropriately. 4. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Deficiencies in Cooking Hood Maintenance and Fire Suppression Inspections
Penalty
Summary
The facility failed to maintain compliance with NFPA 101 and NFPA 96 standards regarding the maintenance of its commercial cooking hood and fire suppression system. During a record review, it was discovered that the facility did not provide evidence of one of the two required semi-annual inspections of the fire suppression system for the year 2024, with the only available inspection dated January 9, 2024. Additionally, the facility failed to conduct the 8-point monthly kitchen quick check inspection regularly, as the only record available was from March 2025. These lapses were acknowledged by the Maintenance Director and the Regional Maintenance Consultant during the review. Furthermore, during a facility tour, it was observed that the commercial cooking hood was not grease-tight, as the seams of the hood were not properly sealed. This deficiency was also acknowledged by the Maintenance Director and the Regional Maintenance Consultant. These findings were discussed with the Administrator, the Maintenance Director, and the Regional Maintenance Consultant during the exit conference, and photographic evidence was obtained to document the issues.
Plan Of Correction
1. Education was provided to the Maintenance Director on ensuring the two semi-annual inspections of the fire suppression system are completed, completing the monthly 8-point kitchen quick check by NHA on 4/1/2025. The commercial cooking hoods seams were resealed to be made grease tight on 04/01/2025 by the Maintenance Director. 2. No other areas or residents were affected by deficient practice. 3. Education was provided to the Maintenance Director by the NHA on 4/1/2025 on ensuring the two semi-annual inspections of the fire suppression system are completed, completing the 8-point monthly kitchen quick check and ensuring the commercial cooking hood seams are sealed and grease tight. The Maintenance Director will conduct quality assurance checks on the commercial cooking hood to ensure seams are sealed and grease tight weekly for 12 weeks. 4. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Non-compliant Installation of ABHR Dispensers
Penalty
Summary
The facility failed to install alcohol-based hand rub (ABHR) dispensers in accordance with NFPA 101 standards in one of its three smoke compartments. During a facility tour conducted with the Maintenance Director and the Regional Maintenance Consultant, it was observed that an ABHR dispenser in the employee lounge was installed within one inch of an ignition source, specifically a light switch or receptacle. Additionally, another ABHR dispenser located in the corridor across from the water heater room was also installed within one inch of an ignition source, a receptacle. These findings were acknowledged by the Maintenance Director and the Regional Maintenance Consultant during the tour. The observations were subsequently reviewed with the Administrator, the Maintenance Director, and the Regional Maintenance Consultant during the exit conference. The report indicates that these installations do not comply with the safety requirements outlined in NFPA 101, which stipulate that dispensers should not be installed within one inch of an ignition source.
Plan Of Correction
1. The ABHR dispenser located in the employee lounge was moved by Maintenance Director on 4/1/2025 and is no longer installed within 1 of an ignition source. The ABHR dispenser located in the corridor across from the water heater room was moved by Maintenance Director on 4/1/2025 and is no longer installed within 1 of an ignition source. 2. An audit was completed by Maintenance Director on 4/17/2025 to ensure all ABHR dispensers are not within 1 of an ignition source. No additional findings noted. 3. Education was provided to the Maintenance Director by NHA on ensuring ABHR dispensers are installed in accordance with NFPA 101 on 4/1/2025. Quality assurance checks will be completed quarterly ongoing at an integrated facility preventive maintenance program. 4. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly to ensure continued compliance.
Failure to Maintain Duct Smoke Detectors
Penalty
Summary
The facility failed to maintain two duct smoke detectors in accordance with NFPA 101 standards. During a record review with the Maintenance Director and the Regional Maintenance Consultant, it was found that the facility did not provide evidence of the required annual duct detector differential pressure testing for the two duct detectors. The most recent testing available was from March 21, 2023, indicating that the annual testing had not been conducted as required. Additionally, the facility did not provide evidence of the biennial sensitivity testing for the two duct smoke detectors. These deficiencies were acknowledged by the Maintenance Director and the Regional Maintenance Consultant during the record review and were discussed with the Administrator during the exit conference. The lack of proper testing and maintenance records for the duct smoke detectors constitutes a failure to comply with the NFPA 101 and NFPA 72 standards.
Plan Of Correction
1. The annual duct detector differential pressure testing for both duct detectors was completed on 2/3/2025 and 3/31/2025. The biennial sensitivity testing for both duct smoke detectors was completed on 03/24/2025. 2. No other areas or residents were affected by deficient practice. 3. Education was provided to the Maintenance Director regarding maintaining the duct detector differential pressure testing and biennial sensitivity testing for both duct smoke detectors per NFPA 101 by NHA on 4/17/2025. 4. Results from the annual duct detector differential pressure testing for both duct detectors and the biennial sensitivity testing for both detectors will be reported to the QA&A committee.
Fire Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its automatic fire sprinkler system in accordance with NFPA 101 standards. During a facility tour, it was observed that a cable related to the facility's satellite system was improperly zip-tied to the fire sprinkler piping located on the exterior of the building. This improper attachment was connected to the fire riser piping, which is a violation of the maintenance standards for fire protection systems. Additionally, a sprinkler located in the medical records storage room was found to contain foreign material, further indicating a lack of proper maintenance and inspection. These deficiencies were identified during an inspection conducted by the Maintenance Director and the Regional Maintenance Consultant. The findings were acknowledged by both the Maintenance Director and the Regional Maintenance Consultant during the inspection and were subsequently reviewed with the Administrator during the exit conference. Photographic evidence was obtained to document these deficiencies, which were found to be in violation of the NFPA 101 and NFPA 25 standards for the inspection, testing, and maintenance of water-based fire protection systems.
Plan Of Correction
1. The Maintenance Director removed the zip tie from the cable related to the facility's satellite system on 4/9/2025. The sprinkler in the medical records storage room was serviced and cleaned by Maintenance staff on 04/2/2025. 2. The Maintenance Director conducted a quality assurance check on sprinkler heads on 4/18/2025. 3. Education was provided to the Maintenance Director by NHA on 4/17/2025 regarding maintaining the automatic fire sprinkler system in accordance with NFPA 101. Ongoing monthly quality assurance checks will be completed by the Maintenance Director or designee on facility sprinkler heads as a part of the facility preventive maintenance program. 4. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly to ensure continued compliance.
Failure to Conduct Required Fire Drills
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101 standards, as evidenced by the absence of documentation for required fire drills. During a record review with the Maintenance Director and the Regional Maintenance Consultant, it was found that the facility did not provide evidence of one of the three required fire drills during the third quarter of 2024 for the second shift. Additionally, there was no evidence of two of the three required fire drills during the fourth quarter of 2024 for the first and third shifts. These findings were acknowledged by the Maintenance Director and the Regional Maintenance Consultant during the record review and were further discussed with the Administrator during the exit conference. The lack of documentation for these fire drills indicates a failure to comply with the established routine of conducting fire drills at unexpected times under varying conditions, as required by NFPA 101.
Plan Of Correction
1. The Maintenance Director in charge of oversight of fire drills in 2024 is no longer with the facility. A fire drill was conducted on each shift of the three shifts during the first quarter of 2025 by the new Maintenance Director. 2. No other areas or residents were affected by deficient practice. 3. Education was provided to the new Maintenance Director by NHA on 4/17/2025 on the requirement to conduct fire drills in accordance with NFPA 101. Monthly audits will be conducted by the Maintenance Director or designee to ensure fire drills are conducted on each of the three shifts monthly. 4. Results from the fire drills will be reported to and reviewed by the QA&A committee.
Unsecured Oxygen Cylinder in Transport Cart
Penalty
Summary
The facility failed to manage an oxygen cylinder in accordance with NFPA 99 standards. During a facility tour conducted by the Maintenance Director and the Regional Maintenance Consultant, it was observed that an e-size oxygen cylinder in a transport cart was unsecured. The cylinder was not properly secured to the cart, which is a violation of the safety standards outlined in NFPA 99. The observations were confirmed through an interview with the Maintenance Director and the Regional Maintenance Consultant, who acknowledged the findings. These findings were subsequently reviewed with the Administrator, the Maintenance Director, and the Regional Maintenance Consultant during the exit conference. Photographic evidence was obtained to document the unsecured oxygen cylinder, further substantiating the deficiency.
Plan Of Correction
1. The e-size oxygen cylinder in transport cart was secured on 03/31/2025 by the Maintenance Director. 2. The Maintenance Director conducted quality assurance check on e-size oxygen cylinders in transport carts to ensure they were secured on 4/1/2025 and no additional findings notes. 3. Education was provided to facility staff on securing e-size oxygen cylinder in transport securely by the NHA or designee by 4/25/2025. The Maintenance Director, or designee, will conduct weekly for 12 weeks audit on 5 random e-size oxygen cylinders in transport carts to ensure they are secured. 4. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Failure to Post Up-to-Date Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that up-to-date nurse staffing information was posted on one of the three days observed by surveyors. On March 24, 2025, at 9:00 AM, the posted staffing information was dated March 22, 2025, with a resident census of 60, indicating that the information was not current. By 10:12 AM on the same day, the staffing posting had still not been updated. The facility's policy, dated November 19, 2019, requires that staffing information, including the facility name, current date, total number, and actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides, be posted daily at the beginning of each shift in a clear and readable format in a prominent place accessible to residents and visitors. The facility is also required to maintain this data for a minimum of 18 months. Photographic evidence was obtained to support these findings.
Plan Of Correction
1. Re-education provided to staffing coordinator by NHA on requirement to post nurse staffing information daily on. 2. No other areas or residents were affected by deficient practice. 3. Reeducation by NHA on was provided to IDT team on requirement for posting up-to-date staffing information daily. 4. The administrator or designee will complete quality assurance check weekly 5X a week for 6 weeks then 3X a week for an additional 6 weeks to ensure up-to-date staffing information is posted daily. 5. All results of the quality assurance checks/audits will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations of improper food storage, labeling, and cleanliness in the kitchen and dining areas. During an initial tour of the kitchen, pliers were found on the dish machine base, and the machine itself had crumbs and food particles on top, with signs of rust on the hood. In the walk-in cooler, vegan bacon was found without a use-by date, and lettuce and potatoes were observed with spoilage and bio growth, respectively. The reach-in refrigerator contained lemons and limes with mold, and a stick of butter was improperly sealed. In the dining room refrigerator/freezer, a food item was labeled with a resident's name but lacked a date, and two ice cream packages were found without any resident identification. The Director of Nursing could not confirm the duration of the food's presence. Interviews with the Kitchen Manager and Certified Dietary Manager revealed that the dish machine's cleanliness was overlooked, and the maintenance staff had left the pliers. The Kitchen Manager stated that all staff are responsible for proper storage, labeling, and dating, and that these topics were discussed in monthly meetings. The facility's policies on labeling, dating, and food storage were reviewed, indicating that leftovers and opened foods should be labeled with a discard date, and food items should be used on a first-in, first-out basis. However, the observations and interviews revealed that these policies were not consistently followed, leading to the deficiencies noted in the report.
Plan Of Correction
1. On the following was completed by kitchen manager: The pliers with a red handle on the machines base in the dish machine area were removed. The top area of the dish machine was cleaned. The dish machine hood was cleaned. The bacon strips in clear storage bag were discarded. The lettuce was discarded. The potatoes were discarded. In refrigerator #2 the lemon and limes and stick of butter were discarded. All items that did not belong to residents with name and date were discarded from dining room refrigerator. 2. Regional dietary manager conducted sanitation and quality audit of facility kitchen on. No other findings were identified. 3. Re-education was provided by Regional Dietary Manager to Kitchen Manager and dietary staff on storage, labeling and dating of food as well as kitchen sanitation. Reeducation was provided to maintenance staff on ensuring tools/equipment are removed from any area if not being actively worked on. Quality assurance checks for sanitation and for proper food storage, labeling and dating will be completed by the Kitchen Manager or designee weekly 3X for 12 weeks. 4. All results of the quality assurance checks/audits will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Failure to Post Nurse Staffing Information on East Wing
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in a manner that was beneficial to residents and the public on the East Wing of the facility. According to the facility's policy, staffing information, including the facility name, current date, total number, and actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides, as well as the resident census, should be posted daily at the beginning of each shift in a clear and readable format. This information should be placed in a prominent location that is readily accessible to residents and visitors. However, during observations at 10:12 AM and 5:45 PM, the staffing board on the East Wing was found to be unchanged, displaying only two nursing staff names and three Certified Nursing Assistant staff names for the 7 AM to 3 PM shift, with no room numbers or shift data posted. The facility's policy also requires that the posted nurse staffing data be maintained for a minimum of 18 months or as required by state law, whichever is greater. Additionally, the facility must make nurse staffing data available to the public upon request. The failure to update the staffing board as required by the facility's policy and state regulations indicates non-compliance with the staffing standards, which are intended to ensure transparency and accessibility of staffing information for the benefit of residents and the public.
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the accuracy of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted to comply with the requirements set forth under state and federal laws and agencies. 1. Re-education provided to East wing nurse from 7am-3pm and East wing nurse from 3pm-11pm by NHA on the requirement to post nurse staffing information in a way to benefit the residents and public. 2. No other areas or residents were affected by deficient practice. 3. Reeducation was provided to nursing staff by DON or designee on requirement for posting up-to-date staffing information daily. 4. The Director of Nursing or designee will complete quality assurance check weekly 5X a week for 6 weeks then 3X a week for an additional 6 weeks to ensure up-to-date staffing information is posted daily. 5. All results of the quality assurance checks/audits will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Failure to Complete Level II PASRR Evaluations
Penalty
Summary
The facility failed to ensure that a Level II Pre-Admission Screening and Resident Review (PASRR) was completed for five residents who were sampled. These residents had various diagnoses, including serious mental illnesses and neurocognitive disorders, which necessitated a Level II PASRR evaluation according to the guidelines. However, the facility did not complete these evaluations, as evidenced by the records and interviews conducted during the survey. Resident #48 was admitted with diagnoses including PTSD, unspecified dementia, and substance abuse, with major depressive disorder added later. The Level I PASRR screen indicated the need for a Level II evaluation due to the presence of a serious mental illness alongside dementia, but this was not completed. Similarly, Resident #29, diagnosed with paranoid schizophrenia and other mental health conditions, did not receive a Level II PASRR despite the chronic nature of their mental illness. Other residents, such as Resident #6, #13, and #2, also had significant mental health diagnoses that warranted a Level II PASRR evaluation. These included conditions like dissociative identity disorder, bipolar disorder, and schizoaffective disorder. The facility's policy required that such evaluations be conducted when indicated by the Level I screen, but the necessary referrals and evaluations were not made. Interviews with the Social Services Director and Director of Nursing revealed a lack of awareness regarding the need to complete these evaluations, contributing to the oversight.
Plan Of Correction
1. Social services director submitted a Level II PASRR request for resident #48 on #13, resident #29 on, resident #6 on, and #2 on. 2. The Social services director will audit residents who have a diagnosis of SMI, ID, and/or related in the facility and if warranted, will submit for level 2 PASRR screen by. 3. Reeducation was provided to the IDT team on the Level II PASRR screen process by NHA or designee on. Ongoing, new admissions to the facility with diagnosis of SMI, ID, and/or related will be audited by social services director or designee within 72 hours of admission for presence of level 2 PASRR screen and submit if warranted. IDT will conduct quality assurance check weekly for 12 weeks on provider documentation to identify any additional diagnoses requiring a level 2 PASRR screen to be initiated. 4. All results of the quality assurance checks/audits will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, and homelike environment in two resident rooms, specifically rooms #201 and #214. In room #201, a resident reported that the dark brown armoire's drawer was broken and could not be opened, which had been an issue for some time. The observation confirmed that the face of the top drawer was separated from the rest of the drawer on the left side. In room #214, the toilet base was not secured to the floor, and both residents in the room confirmed they used the toilet. Staff D, a Certified Nursing Assistant, stated that a work order should be placed in the facility's electronic work order system if repairs are needed, but no such order was found for these issues. The Housekeeping Director stated that housekeeping cleans the bathrooms daily and would inform the Maintenance Director of any repairs needed, as housekeeping staff do not have access to the work order system. However, the Maintenance Director confirmed not having received any work orders for the issues in rooms #201 and #214. The facility was unable to provide a policy for Building/Equipment Maintenance when requested. Photographic evidence was obtained to support these findings.
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the accuracy of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted to comply with the requirements set forth under state and federal laws and agencies. 1. The armoires drawer in was repaired on by the maintenance director. The toilet base in was secured to the floor on by the maintenance director. 2. Quality assurance check of all residents armoires and toilets was completed on by maintenance director. No additional findings were noted. 3. Facility staff received education on utilizing the TELS system for work orders by NHA or designee by . 4. Quality assurance checks on armoires and toilets will be completed by IDT members 3x a week for 6 weeks then 1x a week for an additional 6 weeks. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop an individualized care plan for two residents, leading to deficiencies in addressing their specific needs. Resident #11, who has a history of PTSD, was observed reading a book in a wheelchair and did not respond to an interview attempt. Her roommate mentioned that she is hard of hearing and does not wear hearing aids. Despite having a care plan that included PTSD as a diagnosis, the plan lacked specific interventions related to her triggers and preferences for care. Staff members, including a CNA and the Social Services Director, were unaware of the resident's PTSD triggers, and the care plan did not include individualized interventions to address her trauma history. Resident #9, diagnosed with end-stage renal disease and dependent on dialysis, also had an incomplete care plan. The care plan failed to specify the location of the dialysis shunt and the dialysis center details, which are critical for managing potential complications related to hemodialysis. The MDS Coordinator acknowledged missing updates to the care plan, which should have been individualized and updated as needed. The Director of Nursing confirmed that care plans should be individualized and updated to reflect the resident's needs and conditions. The facility's policies and procedures emphasize the importance of comprehensive, person-centered care plans that include measurable objectives and timeframes. However, the care plans for both residents did not meet these standards, as they lacked specific interventions and updates based on the residents' conditions and needs. The interdisciplinary team is responsible for developing and implementing these care plans, but the deficiencies indicate a failure to adhere to the facility's policies and procedures.
Plan Of Correction
1. The care plan for resident #11 was updated to include interventions related to approach and determining her preference for care by MDS director on. Care plan for resident #9 was updated to include information regarding what center the resident goes to for by MDS director on. 2. MDS director or designee will complete quality assurance checks on resident care plans to ensure they include individualized goals and interventions by. 3. Reeducation was provided to the IDT team that resident care plans must be individualized with goals and interventions. 4. Quality assurance checks will be conducted of four random residents' care plans by the MDS director or designee 3 times a week for 6 weeks, then weekly for an additional 6 weeks to ensure they are individualized with interventions and goals. All results of the quality assurance checks/audits will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify specific triggers related to post-traumatic stress disorder (PTSD) and develop an individualized plan of care to prevent re-traumatization for Resident #11. The resident, who has a history of unspecified dementia, major depressive disorder, generalized anxiety, and PTSD, was observed reading a book and did not respond to an interview attempt. Her care plan mentioned the risk of re-traumatization related to childhood trauma but lacked specific interventions tailored to her needs. Interviews with staff revealed a lack of awareness and training regarding PTSD triggers and individualized care approaches. A Certified Nursing Assistant (CNA) was unaware of Resident #11's PTSD diagnosis and could not identify her triggers. The Director of Nursing (DON) acknowledged that staff are educated to look for behaviors but did not know the resident's specific triggers. The Social Services Director (SSD) confirmed that the care plan should include interventions related to approach and preferences for care but had not individualized triggers for PTSD care plans. The facility's policy on Trauma Informed Care emphasized the importance of culturally sensitive and person-centered care, yet staff interviews indicated a gap in training and implementation. The SSD was aware of the resident's trauma history but had not seen psych notes related to physical and sexual abuse. The deficiency highlights a failure to provide trauma-informed care by not adequately identifying and addressing the resident's PTSD triggers in her care plan.
Plan Of Correction
1. The care plan for resident #11 was updated to include specific triggers related to prevent re- to by the MDS director on. 2. MDS director or designee will complete quality assurance checks on resident care plans to ensure they have an individualized plan to prevent re- by. 3. Reeducation was provided to the IDT team that resident care plans must be individualized and include specific triggers related to, to prevent re- by NHA or designee on. 4. Quality assurance checks will be conducted of four random residents care plans by the MDS director or designee 3 times a week for 6 weeks then weekly for an additional 6 weeks to ensure they are individualized with specific triggers related to to prevent re- to. All results of the quality assurance checks/audits will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in two resident rooms, specifically rooms #201 and #214. In room #201, a resident reported that the dark brown armoire's drawer was broken and could not be opened, which had been an issue for some time. The observation confirmed that the top drawer of the armoire was separated from the rest of the drawer on the left side. In room #214, the toilet base was not secured to the floor, and both residents of the room confirmed they used the toilet. Staff D, a Certified Nursing Assistant, mentioned that if staff noticed anything in need of repair, a work order should be placed in the facility's electronic work order system. The Housekeeping Director stated that housekeeping cleans the bathrooms daily and would inform the Maintenance Director of any repairs needed, as housekeeping staff do not have access to the electronic work order system. The Maintenance Director confirmed not having any work orders for the issues in both rooms and acknowledged the need for repairs upon observation. Additionally, the facility failed to provide a policy for Building/Equipment Maintenance when requested. Photographic evidence was obtained to support these findings.
Plan Of Correction
1. The armoires drawer in was repaired on by the maintenance director. The toilet base in was secured to the floor on by the maintenance director. 2. Quality assurance check of all residents armoires and toilets was completed on by maintenance director. No additional findings were noted. 3. Facility staff received education on utilizing the TELS system for work orders by NHA or designee by. 4. Quality assurance checks on armoires and toilets will be completed by IDT members 3x a week for 6 weeks then 1x a week for an additional 6 weeks. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Latest citations in Florida
Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
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