Aviata At Arbor Springs
Inspection history, citations, penalties and survey trends for this long-term care facility in Ocala, Florida.
- Location
- 1501 Se 24th Rd, Ocala, Florida 34471
- CMS Provider Number
- 105465
- Inspections on file
- 37
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Aviata At Arbor Springs during CMS and state inspections, most recent first.
A resident with multiple mental health diagnoses was transferred to a sister facility over 100 miles away primarily for more lenient smoking times, without documented interdisciplinary discharge planning, resident consent, or a written physician order. Staff interviews gave conflicting reasons for the move, and social services reported no involvement despite facility policy requiring interdisciplinary planning and review with the resident. The resident reported being told abruptly to pack and leave, stated he never signed discharge forms, and said his family and support system remained in his original city, contrary to statements that the transfer would place him closer to family. Records showed no smoking-related care plan, no documented noncompliance with the smoking policy, no exploration of closer placement options, and no evidence that the resident’s preferences and psychosocial needs were considered in the discharge decision.
Two residents were transferred to other SNFs without receiving the required 30-day written notice and without clear evidence of consent or proper discharge orders. In one case, a resident was moved the day after receiving notice, the discharge form lacked the resident’s signature, the resident reported never signing any forms and being told abruptly to pack and leave, and record review showed no MD order for discharge. In the other case, a resident’s daughter/POA reported she was told transfer was only a possibility, was not called back before the move, and later learned the resident was already on the bus; she also reported missing belongings and that the resident was unprepared and unaware the move was permanent. Facility leadership acknowledged that same-day notice was used when a resident was considered agreeable and that a verbal MD order for transfer had been given, despite a written policy requiring interdisciplinary discharge planning and prior review of the discharge plan and proposed date with the resident or representative.
Surveyors found multiple instances of improper labeling and storage of medications on several medication carts, including unlabeled medication cups with tablets, opened insulin vials without open or expiration dates, expired insulin, and ophthalmic solutions lacking required dating. Several unopened insulin vials and other medications labeled by the pharmacy to be refrigerated until opened were instead stored on medication carts. Multiple RNs and LPNs acknowledged during interviews that medications should be labeled with open or expiration dates, expired medications should not remain on carts, and products requiring refrigeration should be kept in a refrigerator, contrary to what was observed. Facility policies require medications to be stored in original labeled containers, under proper conditions per manufacturer instructions, with expired or discontinued medications removed and refrigerated medications maintained at appropriate temperatures.
The facility did not ensure a safe and homelike environment when it failed to repair broken wall tiles in a shower room. A resident reported catching a toe on a missing tile, and surveyors later observed seven broken tiles on a shower room wall, including chipped tiles with sharp edges and deteriorating grout. The Maintenance Assistant acknowledged the tiles were in disrepair and stated that daily shower room tours had not yet included this room that day, despite a facility policy requiring daily rounds to identify and address physical plant hazards.
Nursing staff failed to follow the facility’s hand hygiene policy during multiple medication passes. An RN and an LPN repeatedly prepared medications at the cart, popped pills from blister packs into their bare hands, and entered resident rooms without performing hand hygiene. They touched overbed tables, bed controls, and residents, donned gloves without prior hand hygiene, obtained BPs, and administered medications, sometimes moving directly from one resident to another without cleaning their hands, despite a policy requiring hand hygiene before and after patient care and after contact with inanimate objects in the patient vicinity.
The facility did not provide written notification to residents and their representatives regarding transfers to the hospital, instead giving all transfer documents to EMS and only verbally informing residents of the reason and destination. Multiple LPNs and the DON confirmed this practice, and clinical records lacked documentation of written notification.
A resident with a multi-drug-resistant organism (MDRO) urinary tract infection was placed on contact isolation, requiring staff to use PPE when entering the room. Observation showed a CNA entered the room and handled personal items without donning gown or gloves, despite clear signage and available PPE. Interviews revealed staff misunderstanding of contact precaution requirements, contrary to facility policy and physician orders.
A resident's MDS assessment did not accurately reflect their prescribed controlled carbohydrate, no added salt diet, as indicated by a physician's order. Staff interviews confirmed the discrepancy and the need for the MDS to be updated to match the resident's actual nutritional status.
Two residents did not receive IV therapy care according to professional standards and facility policy. One resident's midline catheter dressing was not changed as required, with dried blood and a compromised dressing observed days after insertion. Another resident had a midline catheter inserted in error due to a misunderstanding of medication orders, resulting in an unnecessary invasive procedure. Staff interviews and documentation confirmed lapses in following orders and established protocols.
A resident with a history of UTIs and a suprapubic catheter was started on Ertapenem for a suspected UTI without clinical or laboratory evidence to support the diagnosis. Despite the absence of fever and normal lab values, the antibiotic was continued after a urine sample was not collected, and no urinalysis or culture was performed. Facility staff acknowledged the failure to obtain the necessary labs and to discontinue the antibiotic in the absence of infection.
A resident with complex medical needs was started on Ertapenem for a suspected UTI without supporting clinical evidence or laboratory confirmation. Despite orders for urinalysis and urine culture, no samples were collected, and the antibiotic was continued without follow-up or discontinuation. Staff interviews confirmed that the facility's antibiotic stewardship policy was not followed, resulting in unmonitored antibiotic use.
A resident with chronic respiratory conditions was observed receiving oxygen at 2 liters per minute, contrary to the physician's order of 5 liters per minute with humidification. The DON confirmed the discrepancy, highlighting the need for staff to verify and follow physician orders.
The facility did not post daily nurse staffing information as required. On observation, the staffing information in the lobby was outdated by three days. The Administrator confirmed the expectation for daily updates but admitted there was no policy for posting this information.
A resident with multiple health conditions was unable to be transferred out of bed for three days due to dead batteries in the mechanical lift. Staff reported issues with battery charging and were unable to find charged batteries in other units. The DON was unaware of the problem, and the resident remained in bed due to the equipment malfunction.
The facility failed to maintain a clean environment, with multiple observations of dead pests and cobwebs in residents' rooms. Residents expressed dissatisfaction with the presence of bugs, and the housekeeping staff acknowledged the issue. The Housekeeping Supervisor noted that rooms should be cleaned daily, but the facility's approach to pest control may have contributed to the problem.
A resident with pressure ulcers did not receive the ordered dietary supplement, Juven, on multiple occasions. The LPN and dietician were unaware of its unavailability and did not inform the physician. The DON emphasized the importance of following physician orders and notifying them if orders cannot be fulfilled.
A resident fell while transferring from a wheelchair to a bed due to malfunctioning bed locks. Despite previous reports of bed issues, the facility lacked a routine maintenance schedule and staff awareness regarding bed safety checks. The Director of Nursing confirmed no corrective actions or staff education were initiated following the incident.
The facility failed to ensure proper hand hygiene and infection control practices during medication administration, wound care, and other resident care activities. Staff did not follow enhanced barrier precautions for residents with indwelling medical devices and wounds, and there was a lack of signage and PPE availability. These deficiencies were observed across multiple staff members and residents, leading to potential risks of infection.
The facility failed to ensure proper medication administration for residents with enteral tubes and central catheters. Nurses did not verify tube or catheter placement, flush between medications, or follow proper procedures for crushing and administering medications. Additionally, a resident was observed self-administering medication left at their bedside.
The facility failed to provide appropriate wound care for multiple residents, including not changing dressings daily as ordered and not following proper infection control procedures. Residents reported and observations confirmed that wound care was often neglected, leading to improper wound management.
The facility failed to provide appropriate enteral nutrition care for two residents. One resident received incorrect feeding and flush rates, while another had outdated gastric tube dressings and was not evaluated for the necessity of the feeding tube despite consuming food and medication orally.
The facility failed to ensure accurate medical records for several residents, leading to deficiencies in wound care, central catheter care, and feeding tube care. Multiple instances of missing documentation were observed, and staff interviews confirmed that care was not documented as required.
The facility failed to develop a comprehensive care plan for a resident who only speaks Spanish, resulting in communication difficulties. The resident's primary language was noted in the MDS, but this information was not included in the care plan, contrary to the facility's policy and procedures.
The facility failed to provide appropriate respiratory care for two residents. One resident received incorrect oxygen levels, and an LPN did not follow sterile technique during a tracheal suctioning procedure. Another resident received oxygen via nasal cannula instead of the prescribed tracheostomy collar.
Failure to Conduct Resident-Centered, Planned Transfer and Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, orderly, and person-centered transfer/discharge for a resident with significant mental health diagnoses, including major depressive disorder, brief psychotic disorder, other specified persistent mood disorders, and generalized anxiety disorder. The resident was discharged to another skilled nursing facility located approximately 115 miles away from the current facility, in a different city from the resident’s identified family and support system. The Nursing Home Transfer and Discharge Notice listed the reason for transfer as access to more frequent/lenient smoking times, was signed by the DON and an APRN, and showed the resident’s name printed but no resident signature. Record review showed no evidence that the resident or a resident representative participated in the discharge decision-making process, no documentation that the resident consented to the transfer, and no documentation that the resident’s preferences and psychosocial needs were considered. Staff interviews revealed inconsistent and incomplete information regarding the rationale for the discharge and the process followed. The LPN Unit Manager stated she was not sure why the resident was discharged but believed it was related to smoking times and reported the resident was told only the day before that he was leaving. The DON and Administrator both stated the resident was transferred because the receiving facility had more lenient smoking times, and the Administrator stated that smokers had been discharged to sister facilities for this reason and that residents were “fine with going.” The Assistant DON reported that the resident was given notice and that she was told the resident was fine with the transfer, but she did not speak with the resident personally. The Director of Social Services reported no involvement in the discharge, noted that residents should consent and sign the discharge notice, and stated she began working at the facility shortly before the discharge date. Another APRN stated the resident was transferred because he wanted to be closer to family and have more lenient smoking access, but also stated she found this strange because she believed the resident did not smoke. Record review and interviews also showed multiple process failures related to discharge planning and documentation. The resident’s smoking assessment documented that the resident currently smoked and did not wish to quit, but the care plan contained no smoking-related focus or interventions, and there was no documentation of noncompliance with the facility’s smoking policy. The facility’s own smoking schedule showed multiple supervised smoking times throughout the day, and the Administrator and Medical Director both referenced smoking restrictions and recent safety mag locks on doors as reasons the resident’s needs could not be met, yet there was no documentation that alternative, closer placement options were explored or that the resident met regulatory criteria for discharge due to the facility’s inability to meet needs. The Medical Director stated he gave a verbal order for transfer but was unsure why the resident was transferred and did not know if other interventions were tried. Review of physician orders showed no written discharge order, and the ADON confirmed there were no discharge or transfer orders in the record. The facility’s Interdisciplinary Discharge Planning policy required development and ongoing review of an interdisciplinary discharge plan and review of the plan and proposed discharge date with the resident or representative, but the record lacked evidence that an effective discharge plan was developed or implemented. The resident reported that he was abruptly informed by a nurse to pack his belongings and leave after breakfast, was transported in a minivan without having signed any discharge forms, and believed someone else signed his discharge form. He stated he had family, including a daughter, grandchildren, and fiancée, living in his original city and that he was not closer to them after the transfer, contrary to what he reported the DON had told him. He described feeling sad and depressed at the new facility, reported he was not allowed to go outside, and stated he thought the transfer was retaliation for complaints he had made about CNAs sleeping. The Administrator stated that if a resident is agreeable to go somewhere else, discharge notice can be given on the same day, and acknowledged there should be a doctor’s order for transfer. The Administrator also stated he did not know whether the receiving facility actually had more liberal smoking policies. Overall, the documentation and interviews showed the facility failed to involve the resident in discharge planning, failed to document consent and appropriate orders, failed to explore closer placement options, and based the transfer primarily on smoking policy without demonstrating inability to meet the resident’s needs in accordance with facility policy and regulatory requirements. The resident’s account and the lack of documentation of involvement of social services, therapy, or an interdisciplinary team in planning the discharge further demonstrate that the facility did not follow its Interdisciplinary Discharge Planning policy. The policy required that discharge needs and goals be developed upon admission, monitored by the interdisciplinary team, and reviewed with the resident or representative prior to discharge, including the proposed discharge date. In this case, the Director of Social Services reported no involvement, the APRN stated she relied on social services and therapy for discharge readiness but was not involved in notice timing, and there was no evidence in the record of an interdisciplinary review of the discharge plan. The facility also failed to document that the resident’s stated goals, family location, or psychosocial status were considered in determining the discharge destination, despite the resident’s mental health diagnoses and his report that his family and support system remained in the original city. These combined actions and omissions led to a transfer that did not demonstrate alignment with the resident’s needs and preferences and lacked the required planning, documentation, and resident participation.
Failure to Provide Timely Written Transfer/Discharge Notice and Obtain Proper Consent
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notice of transfer or discharge at least 30 days in advance and to obtain appropriate consent and orders for two residents. For one resident, the Nursing Home Transfer and Discharge Notice showed a transfer to another skilled nursing facility on 2/20/2026, with the notice provided on 2/19/2026 and an effective date of 2/20/2026. The form was signed by the Director of Nursing and an APRN, but the resident’s signature line was blank. The resident reported being told abruptly by a nurse to pack belongings and leave after breakfast, stated they never signed any forms, and asserted that the signature on the discharge form was not theirs. Record review showed no physician order for discharge or transfer, and the Assistant Director of Nursing confirmed there were no such orders for this resident. The Director of Social Services stated that if a resident is being transferred to another facility, they would need to consent and sign the discharge notice. For another resident, the Nursing Home Transfer and Discharge Notice documented a same-day notice and transfer to a facility closer to the resident’s daughter, with the notice provided and effective on the same date. The resident’s daughter/POA reported she had no advance notice before the transfer, was initially told transfer was only a possible option, and that she wanted to discuss it with the resident before any move occurred. She stated no one called her back, and when she attempted to follow up, the resident was already on the bus being transferred. She also reported that many of the resident’s belongings did not accompany the resident, that she was told all belongings were in one box at the receiving facility, and that the resident was not prepared for the transfer and did not realize it was permanent. The Administrator stated that if a resident is agreeable to go somewhere else, discharge notice can be given on the same day, and that there should be a doctor’s order for transfer, indicating a verbal order had been given by the Medical Director to the DON. The facility’s Interdisciplinary Discharge Planning policy required that discharge needs, goals, and estimated length of stay be developed upon admission, that progress toward discharge goals be monitored and plans revised as appropriate, and that the discharge plan, including the proposed discharge date, be reviewed with the resident or representative prior to discharge.
Improper Labeling and Storage of Insulin and Other Medications on Multiple Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals, particularly insulin and ophthalmic solutions, were properly labeled, stored, and maintained in accordance with professional standards and facility policy. During observation of medication cart #1 with an RN, surveyors found two unlabeled medication cups containing multiple tablets, as well as several insulin vials that were either opened without a date or expired, and multiple unopened insulin vials labeled by the pharmacy to be refrigerated until opened but stored on the cart instead. The RN acknowledged that medications should not be unlabeled, should not be pre-poured and left on the cart, and that insulin requiring refrigeration should not be kept on the cart and that expired insulin should not be present. On medication cart #2, observed with an LPN, surveyors identified an unopened Lispro insulin that should have been refrigerated until opened and multiple Latanoprost and Timolol ophthalmic solutions that were either missing open dates or expiration dates, with the LPN stating that all medicines should be in the refrigerator if required, labeled with open dates, and removed if expired, and acknowledging that the eye drops were expired. On medication cart #4, another LPN was observed with Lantus and Novolin insulin vials that lacked open dates or expiration dates, along with an unopened Lantus insulin that should have been refrigerated until opened; the LPN stated that all medications should have open or expiration dates and remain refrigerated until needed. On medication cart #5, surveyors found multiple unopened insulin vials labeled to be refrigerated until opened stored on the cart, an opened Lantus insulin without pharmacy packaging or resident identification and without open or expiration dates, an opened Aspart insulin without dates, and two expired insulin vials with documented open dates; the LPN confirmed there should not be expired medicines on the cart and that insulins should be labeled and refrigerated when not in use. Further observations on medication carts #6 and #7 revealed additional issues with insulin storage and labeling. On cart #6, there were unopened Aspart and Lantus insulin vials labeled to be refrigerated until opened and an opened Lispro insulin without an open date or expiration date; the LPN stated that every insulin should have an open or expiration date and that unused insulin should remain in the refrigerator. On cart #7, surveyors found an expired Lispro insulin with an open date, unopened Glargine and Humulin insulins that were labeled to be refrigerated until opened but stored on the cart, and an opened Novolin insulin without an open date or expiration date; the LPN stated that every insulin needs expiration dates and unopened insulins should stay in the refrigerator. Review of facility policies confirmed that medications are required to be stored in original labeled containers, under proper conditions per manufacturer instructions, with expired or discontinued medications removed, and that medications requiring refrigeration must be stored at 2–8°C (36–46°F).
Failure to Maintain Safe and Intact Shower Room Surfaces
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment when it did not repair broken and damaged wall tiles in a resident shower room. A resident reported that there was a missing shower tile in the shower room and that she caught her toe on it in January. On observation of the 400's hall shower room, surveyors noted seven broken wall tiles on the wall adjacent to the door, including two tiles that were chipped with sharp edges exposed and an uneven surface with deteriorating grout. During interview, the Maintenance Assistant acknowledged that the tiles were in disrepair and stated that he tours the shower rooms daily but had not yet toured this particular shower room that day. Review of the facility’s Maintenance policy, last approved on 01/15/2026, showed that the Director of Environmental Services is responsible for daily rounds of the building to ensure the physical plant is free of hazards and in proper condition, indicating that the damaged tiles were not identified and corrected as required by the facility’s preventive maintenance procedures.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not ensuring staff performed required hand hygiene during medication administration. During multiple observations of medication passes, a Registered Nurse (Staff A) and a Licensed Practical Nurse (Staff C) repeatedly approached and used the medication cart, unlocked it, activated and typed on the computer, and prepared medications without performing hand hygiene. Staff A was observed popping multiple medications from blister packs directly into their bare hand before placing them into medication cups for several residents, and then entering resident rooms without hand hygiene, touching overbed tables, bed controls, and residents, and donning gloves without prior hand hygiene before taking blood pressures and administering medications. Staff A acknowledged during interview that they should not have touched the medications with their hands and should have used hand sanitizer more frequently. Similarly, Staff C was observed returning to the medication cart multiple times, unlocking it, activating and typing on the computer, and preparing medications for several residents without performing hand hygiene. Staff C then entered resident rooms without hand hygiene, touched overbed tables, bed controls, and residents, obtained blood pressures, and administered medications, and in some instances exited rooms and immediately began preparing medications for other residents without performing hand hygiene. During interview, Staff C stated they should have used the hand sanitizer available on the cart. Review of the facility’s “Hand Hygiene” policy, last approved on 1/15/2026, showed that hand hygiene is required before and after patient care and after contact with inanimate objects in the immediate patient vicinity, which was not followed in these observed instances.
Failure to Provide Written Transfer Notification to Residents and Representatives
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding transfers to the hospital, including the reasons for the transfers, for three residents reviewed for discharge or transfer. Clinical records for each resident contained transfer forms and discharge notices indicating the date and destination of the transfer, but there was no documentation that written notification was given to the residents or their representatives. Instead, staff reported that all transfer documents were provided to EMS, and only verbal explanations were given to the residents about the reason for transfer and the destination. Interviews with multiple LPNs and the Director of Nursing confirmed that the practice was to verbally inform residents of the transfer and provide all paperwork to EMS, rather than directly to the residents or their representatives. Staff also indicated that they did not provide written documentation to residents at the time of transfer, citing concerns that the paperwork might get lost. The facility's policy stated that transfers or discharges should be safe, orderly, and appropriate to meet the needs of the resident, but did not specify the process for written notification to residents or their representatives.
Failure to Follow Contact Precaution Protocols for Resident with MDRO UTI
Penalty
Summary
Staff failed to follow established infection control standards for transmission-based precautions for a resident admitted with a diagnosis of pseudomonas aeruginosa urinary tract infection, a multi-drug-resistant organism. Physician orders and facility policy required contact isolation, including the use of personal protective equipment (PPE) such as gowns and gloves upon entering the resident's room. Observation revealed that a CNA entered the resident's room without donning any PPE, despite clear signage and readily available PPE at the door. The CNA handled the resident's personal belongings on the bedside table and then exited the room without wearing gloves or a gown. Interviews with the CNA, LPN supervisor, and Director of Nursing confirmed that staff were expected to wear appropriate PPE when entering rooms under contact precautions. The CNA stated a misunderstanding of the requirements, believing PPE was only necessary when directly caring for the resident, not when entering the room or handling items. Facility policy and posted signage both specified that gloves and gowns must be worn upon entry to the room, regardless of the nature of the visit, to prevent the spread of infection.
Inaccurate MDS Assessment of Resident's Therapeutic Diet
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the nutritional status of a resident. Specifically, the annual Minimum Data Set (MDS) for one resident indicated that the resident was not on a therapeutic diet, as documented under Section K - Swallowing/Nutritional Status. However, a physician's order dated several months prior specified that the resident was to receive a controlled carbohydrate diet with no added salt. During interviews, the MDS Coordinator acknowledged that the MDS would need to be modified to reflect the resident's actual diet, and the Director of Nursing confirmed that the MDS should accurately represent the resident's information.
Failure to Follow IV Therapy Standards and Orders for Two Residents
Penalty
Summary
The facility failed to provide care and services according to professional standards of practice for two residents receiving IV therapy. For one resident, a midline catheter was inserted in the left upper arm for IV fluids, but the transparent dressing over the insertion site was observed to be lifting at the edges, with dried blood visible on gauze beneath the dressing. The dressing was dated nine days prior and had not been changed as required by both physician orders and facility policy, which specify dressing changes every 5-7 days or sooner if compromised, and every 48 hours if gauze is present. Staff interviews confirmed the dressing should have been changed, and the resident reported it had not been changed since insertion. Another resident had a midline catheter inserted in error after staff misinterpreted medication orders, believing IV access was needed for antibiotic administration. The resident received all doses of the prescribed medication intramuscularly, as originally intended, and the midline was removed the following day after the mistake was identified. Documentation and staff interviews revealed that the midline was not used for medication administration, and the error was due to a misunderstanding of the medication route. The advanced practice provider confirmed that no order was given for IV administration or midline insertion. Facility policy requires a provider order and written consent for midline or PICC insertion, and specifies dressing change intervals to prevent infection. In both cases, the facility did not follow its own policies or professional standards, resulting in improper catheter care and an unnecessary invasive procedure.
Unnecessary Antibiotic Use Without Laboratory Confirmation
Penalty
Summary
A deficiency occurred when a resident with a history of urinary tract infections (UTIs) and a suprapubic catheter was started on Ertapenem, a broad-spectrum antibiotic, for a suspected UTI without adequate clinical indications or supporting laboratory evidence. The physician ordered a urinalysis with reflex culture, but the urine sample was not collected, and no urinalysis or urine culture results were documented. Despite the absence of fever, normal white blood cell count, and lack of other clinical signs of infection, the antibiotic regimen was continued. Interviews with facility staff, including the Infection Preventionist, LPN, DON, and Advanced Practice Registered Nurse, confirmed that the antibiotic should not have been continued without laboratory confirmation of infection. Staff acknowledged that there was a failure to follow up on obtaining the necessary urine sample and to discontinue the antibiotic in the absence of supporting evidence. This resulted in the resident receiving unnecessary antibiotics, contrary to facility policy and best practices for antimicrobial stewardship.
Failure to Monitor and Manage Antibiotic Use per Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program by not adequately monitoring and managing the use of antibiotics for a resident with multiple complex medical conditions, including quadriplegia, tracheostomy, and a history of urinary tract infections (UTIs). The resident was started on Ertapenem for a suspected UTI based on a physician's order, despite the absence of clinical signs such as fever or elevated white blood cell count. Although a urinalysis and urine culture were ordered, no samples were successfully collected, and there were no laboratory reports or follow-up orders for these tests during the relevant period. Staff interviews revealed that the antibiotic was continued without confirmation of infection, and there was a lack of follow-up to obtain the necessary urine sample or to discontinue the antibiotic in the absence of supporting evidence. The Infection Preventionist, LPN, DON, and Advanced Practice Registered Nurse all acknowledged that the facility's antibiotic stewardship policy was not followed, as antibiotics were administered empirically without culture results or clear clinical indications, and appropriate communication and documentation were lacking.
Failure to Administer Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure that a resident received the correct oxygen flow rate as prescribed by their physician. During observations, it was noted that the resident was receiving oxygen at a flow rate of 2 liters per minute via a tracheostomy mask, despite the physician's order specifying a flow rate of 5 liters per minute with humidification. The resident, who was admitted with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and sleep apnea, was not receiving the prescribed level of oxygen. The Director of Nursing confirmed that the resident's oxygen flow rate was incorrect and emphasized that staff should review and verify physician orders to ensure compliance with prescribed treatments.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted on a daily basis. During an observation on February 6, 2025, at 8:45 AM, it was noted that the nurse staffing information displayed in the front lobby was outdated, showing the date of February 3, 2025. In an interview conducted on the same day at approximately 9:00 AM, the Administrator acknowledged that the expectation was to have the staffing information posted and readily available with the correct information at the beginning of each shift. However, it was revealed that the facility did not have a policy in place for posting the nurse staffing information.
Failure to Transfer Resident Due to Equipment Malfunction
Penalty
Summary
The facility failed to ensure that a resident was transferred out of bed using a mechanical lift, as required by their care plan. The resident, who had multiple diagnoses including type 2 diabetes mellitus, hypertension, obesity, and a history of cerebrovascular accident, was unable to be transferred out of bed for three consecutive days due to dead batteries in the Hoyer lift. The resident expressed that the lift had dead batteries from Friday to Sunday, preventing them from getting out of bed. Interviews with staff members revealed that there was an ongoing issue with the batteries not charging properly. Staff members attempted to find charged batteries by checking other units but were unsuccessful. The Director of Nursing was unaware of the battery issue and stated that staff were expected to obtain batteries from other areas if needed. Despite these expectations, the resident remained in bed due to the lack of functioning equipment.
Facility Fails to Maintain Clean Environment Due to Pest Presence
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by multiple observations of dead pests and cobwebs in several residents' rooms. During an observation, a dead brown small pest was found in a cobweb high on the wall in a resident's room. The resident expressed dissatisfaction with the presence of bugs in their room. Another resident's room had peeling baseboards with multiple dead pests inside, as well as cobwebs containing dead pests on the walls and above the windows. This resident reported seeing live bugs, particularly in the bathroom, and expressed uncertainty about whether the facility had conducted pest control measures. The housekeeping staff, including a housekeeper and the Housekeeping Supervisor, acknowledged the presence of dead pests in cobwebs during their observations. The Housekeeping Supervisor confirmed that the rooms should be cleaned and dusted daily, with cobwebs and bugs removed regularly. He noted that the facility was treating one hall at a time, which might have contributed to the issue of bugs in some rooms. The observations and interviews indicate a failure to provide a clean and safe environment for the residents, as required by regulations.
Failure to Administer Dietary Supplement as Ordered
Penalty
Summary
The facility failed to provide a dietary supplement, Juven, as ordered for a resident with pressure ulcers, paraplegia, muscle wasting, and atrophy. The physician's orders specified that Juven should be administered twice daily, but the Medication Administration Record showed that it was not given on several occasions. There was no documentation indicating that the physician or nutritionist was informed about the unavailability of the supplement. Interviews revealed that the resident expressed concern about not receiving the supplement, which was intended to aid in wound healing. Staff members, including an LPN and the dietician, confirmed that they were unaware of the supplement's unavailability and did not notify the physician. The Director of Nursing stated that physician orders should be followed, and any inability to do so should be communicated to the physician.
Failure to Maintain Bed Safety Leads to Resident Fall
Penalty
Summary
The facility failed to ensure a safe environment for a resident by not maintaining the functionality of the bed locks, which led to an accident. A resident, who had a history of independently transferring from a wheelchair to a bed, reported that the bed was not locked, causing it to move and resulting in a fall. The resident had previously reported issues with the bed, including a malfunctioning lock and problems with the bed not lowering, which were documented in work orders. Despite these reports, there was no evidence of a routine maintenance schedule to check the beds for safety, and the maintenance director confirmed that checks were only performed when issues were reported by residents or staff. Interviews with staff, including the Director of Nursing and a Registered Nurse, revealed a lack of awareness and responsibility for checking bed functionality. The Director of Nursing acknowledged that no corrective plan was initiated after the bed malfunction was identified, and no routine checks or staff education on bed safety were implemented. This lack of proactive measures and communication contributed to the unsafe environment that led to the resident's fall.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure staff performed proper hand hygiene during medication administration, wound care, and other resident care activities. Multiple observations revealed that staff members, including RNs and LPNs, did not wash their hands or use hand sanitizer before and after administering medications, handling medical equipment, or performing wound care. This was observed across several residents, including those with complex medical needs such as gastrostomy tubes, tracheostomies, and stage 4 pressure ulcers. Staff members admitted to not following hand hygiene protocols during interviews, and the facility's policies clearly outlined the necessity of hand hygiene to prevent the spread of infection. The facility also failed to implement enhanced barrier precautions for residents with indwelling medical devices and wounds. Observations showed that there was no signage indicating enhanced barrier precautions, and PPE supplies were not available in or near the rooms of affected residents. Staff members did not don gowns when providing high-contact care activities, such as wound care, tracheostomy care, and medication administration via gastrostomy tubes. Interviews with staff revealed a lack of awareness and adherence to the enhanced barrier precautions, despite physician orders and care plans indicating the need for such measures. Additionally, the facility did not follow proper infection control standards during wound care procedures. Staff members were observed not cleaning overbed tables before placing wound care supplies, not performing hand hygiene between glove changes, and contaminating sterile supplies by touching non-sterile surfaces. These actions were contrary to the facility's policies on dressing changes and wound care, which emphasized the importance of maintaining a sterile environment to promote healing and prevent infections. The Director of Nursing acknowledged the deficiencies and stated that staff should follow the established policies and procedures for infection control.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper medication administration for residents with enteral tubes and central catheters. During an observation, a registered nurse administered medications to a resident with an enteral tube without verifying tube placement, flushing between medications, or using gravity flow. The nurse admitted to not following the facility's policy, which requires checking for gastric residual volume and flushing the tube with water between each medication. Another incident involved a resident with a midline catheter where the nurse did not properly clean the needleless connector, verify catheter placement, or assess the insertion site before administering IV medication. The Director of Nursing confirmed the lack of a specific central line flush policy and expected procedures were not followed. Additionally, a resident was observed self-administering medication left at their bedside, which is against facility policy. Another nurse was seen crushing and administering multiple medications together via a gastric tube, contrary to the policy that requires each medication to be crushed and administered separately. The Director of Nursing acknowledged that the staff did not adhere to the proper procedures for medication administration via enteral tubes and that medications should not be left at the bedside for residents who are not capable of self-administration.
Failure to Provide Appropriate Wound Care
Penalty
Summary
The facility failed to ensure that residents received wound care treatment in accordance with professional standards of practice. Resident #91, who had a stage 4 pressure ulcer, did not receive daily wound care as ordered by the physician. The dressing was observed to be dated incorrectly, and there were multiple days where no entries were documented in the Treatment Administration Record. Additionally, a family member had to perform wound care due to the facility's inaction, and staff failed to follow proper infection control procedures during care observations. Resident #73 had a left heel dressing that was not changed daily as required. The resident reported that staff often forgot to change the dressing, and observations confirmed that the dressing was not changed for several days. Staff interviews corroborated that the dressing should have been changed daily but was not. Resident #133 and Resident #155 also did not receive appropriate wound care. Resident #133's right thigh dressing was not changed daily as ordered, and the resident reported that staff had not attended to the wound care as required. Resident #155 had a surgical wound with a dressing that was not changed according to the physician's orders, and the wound vac was not applied due to a lack of supplies. The facility's documentation and staff interviews confirmed these deficiencies in wound care treatment.
Failure to Ensure Appropriate Enteral Nutrition Care
Penalty
Summary
The facility failed to ensure appropriate care and services for enteral nutrition for two residents. For Resident #96, observations revealed discrepancies between the physician's orders and the actual administration of the feeding and flush rates. The resident's feeding machine was found beeping with empty formula and water bags, and the feeding rate was consistently observed at 50 ml/hr, contrary to the physician's order of 55 ml/hr. Additionally, the autoflush rate was running at 60 ml/hr instead of the ordered 40 ml/hr. The resident experienced a slight weight loss, which the Registered Dietician noted could be affected by the incorrect feeding rate. The Director of Nursing confirmed that nurses should verify the orders and the milliliters that a feeding and flush should be running. For Resident #151, the facility failed to change the gastric tube dressing as per the physician's orders. The resident's tube feeding dressing was observed to be dated several days prior, and the resident reported that the dressing had not been changed for days. The resident also mentioned that they no longer needed the feeding tube as they were consuming food and medication orally. Physician orders indicated a regular diet and daily dressing changes, which were not followed. The Director of Nursing acknowledged that the resident should have been evaluated earlier and that the dressing should be changed daily according to physician orders.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to ensure accurate medical records for several residents, leading to deficiencies in wound care, central catheter care, and feeding tube care. For Resident #91, there were multiple instances where wound care and tracheostomy care were not documented in the Treatment Administration Record (TAR) for May 2024. This included missing entries for cleansing and dressing the coccyx and tracheostomy site, as well as suctioning the tracheostomy tube. Similarly, Resident #260's TAR showed missing documentation for wound care and enteral tube care on several dates in May 2024. Resident #73's TAR also lacked documentation for wound care on specific dates in May 2024. During an interview, a Licensed Practical Nurse (LPN) confirmed that all wound care should be documented, and the Director of Nursing (DON) stated that nurses should follow accepted standards for documentation. Resident #133's right thigh dressing was observed to be dated incorrectly, and the TAR showed discrepancies in the administration of care. The DON confirmed that staff should follow physician orders for treatment. Resident #151's tube feeding dressing was observed to be outdated, and the resident reported that the dressing had not been changed for days. The TAR showed staff initials for care that was not provided. Resident #155 had a visibly soiled abdominal wound dressing, and the TAR showed missing entries for wound care. The DON stated that nursing staff should document accurately and as needed in the resident treatment record.
Failure to Develop Comprehensive Care Plan for Language and Communication
Penalty
Summary
The facility failed to develop a comprehensive care plan for language and communication for a resident who only speaks Spanish. During an interview, the resident expressed difficulty in communicating with staff due to the language barrier. The resident's Medicare 5-Day Minimum Data Set (MDS) indicated that Spanish was the resident's primary language, but this information was not included in the resident's care plan. This omission was confirmed during an interview with the MDS Coordinator, who acknowledged that the resident's communication needs were not addressed in the care plan. The facility's policy and procedures for developing care plans require that an individualized, person-centered plan of care be established by the interdisciplinary team (IDT) and updated in accordance with state and federal regulatory requirements. The policy also mandates that the care plan should include measurable objectives and timetables to meet the resident's needs. Despite these requirements, the care plan for the resident did not address the language and communication needs, leading to a deficiency in providing appropriate care for the resident's specific needs.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care services for two residents. Resident #91, who was admitted with acute and chronic respiratory failure and tracheostomy status, had a physician's order for oxygen administration at 4 liters per minute via tracheostomy collar. However, observations on multiple occasions showed the resident receiving oxygen at 5 liters per minute. Additionally, during a tracheal suctioning procedure, an LPN did not follow sterile technique and failed to assess breath sounds before and after the procedure, contrary to the facility's policy and procedures for suctioning ventilator-dependent residents. Resident #96, who had a history of pneumonia, interstitial pulmonary disease, respiratory failure, and tracheostomy status, had a physician's order for oxygen administration at 4 liters per minute via tracheostomy collar. However, observations showed the resident receiving oxygen at 3 liters per minute via nasal cannula. The care plan for Resident #96 indicated the need for oxygen administration as ordered, but staff failed to ensure the correct oxygen rate was administered. The DON confirmed that staff should check and adjust the oxygen rate to match the physician's order.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
