Aviata At Saint Lucie
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Pierce, Florida.
- Location
- 611 S 13th St, Fort Pierce, Florida 34950
- CMS Provider Number
- 105257
- Inspections on file
- 30
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Aviata At Saint Lucie during CMS and state inspections, most recent first.
Two residents did not receive care in accordance with professional standards. One resident on warfarin for a valve replacement had invalid initial PT/INR labs, an order to hold warfarin pending results, and later dose changes, yet MAR entries showed warfarin was administered on days it should have been held, including when INRs were elevated and critically high, with no evidence the physician was contacted or that ordered follow-up INRs were drawn as prescribed. Another resident’s medication pass was observed where an LPN correctly administered six oral medications and held insulin for a blood sugar of 109, but later documented on the MAR that a polyethylene glycol 3350 dose had been given when it had not; after being questioned, the LPN retrieved the medication from the supply room and administered it after signing for it.
A resident on warfarin for a mechanical heart valve had critically elevated PT/INR values documented, yet nursing staff continued to administer warfarin, including during a period when the drug was ordered to be held. The MAR shows doses given on days when INRs were elevated, with no evidence that the physician was notified before administration. After a critically high INR, the provider ordered vitamin K and daily PT/INR labs for two days, but the ordered labs were not drawn as scheduled, and the next INR was not obtained until after the resident became nonresponsive and stopped eating. The DON later confirmed that the labs were missed and that there was no documentation of timely physician contact regarding the elevated INRs.
Surveyors identified that nursing staff failed to follow physician orders and professional standards for medication administration for two residents. One resident on an anticoagulant had orders to hold and later adjust dosing based on INR results, yet MAR entries showed doses documented as given on days when the drug was ordered held, and the medication was administered despite documented critically elevated INR values without evidence of physician notification or timely completion of ordered follow-up INR labs. Pharmacy records also conflicted with MAR documentation regarding the number of anticoagulant doses actually administered. In a separate observation, a nurse administered six verified oral medications to another resident but then documented on the MAR that a polyethylene glycol dose had been given when it had not; after being questioned, the nurse acknowledged the discrepancy, located the medication in the supply room, and administered it afterward.
A resident with a history of valve replacement was prescribed an anticoagulant with specific dosing and INR monitoring orders, but staff failed to follow these orders and professional standards. INR labs were initially invalid, and although subsequent results showed elevated and then critically high INR values, nurses documented administering ordered doses without evidence of contacting the physician for guidance. Ordered follow-up INR labs after a critically high result were not drawn on the specified days, and there was no documented follow-up with the lab. Pharmacy records showed that nearly all dispensed tablets were returned despite MAR entries indicating multiple doses were given, and the DON confirmed the lapses in lab completion, physician notification, and medication administration documentation.
Two residents did not receive care and treatment according to physician orders and professional standards. One resident with a prosthetic heart valve had warfarin therapy managed inconsistently with orders: warfarin was documented as given on days when it was ordered to be held, doses were administered despite elevated and critically high INR values without documented physician notification, and ordered follow-up PT/INR labs were not drawn on the specified days, with no evidence of staff follow-up. Pharmacy records also showed a discrepancy between warfarin tablets dispensed, tablets returned, and doses documented as administered. For another resident, an LPN administered six verified oral medications during an observed pass and held insulin appropriately, but then documented on the MAR that polyethylene glycol had been given when it had not; after acknowledging this, the LPN located the medication from the supply room and administered it, indicating inaccurate medication administration documentation.
A resident with a prosthetic heart valve on warfarin therapy had significantly elevated INR values, yet nursing staff continued to administer warfarin without documented physician notification or guidance and in conflict with hold orders. PT/INR monitoring was ordered but not consistently completed as prescribed, including missed ordered labs on consecutive days, and there was no evidence of staff follow-up with the lab to ensure testing occurred. The resident subsequently exhibited lethargy, decreased responsiveness, and poor oral intake, leading to further evaluation and hospital transfer, and the DON later confirmed the lapses in lab monitoring and lack of documented provider contact.
A resident with cancer and significant functional limitations, who required staff assistance for showering and personal hygiene, did not receive scheduled showers as documented in the care plan. Over a 30-day period, there was no evidence in CNA records or shower logs that showers were provided or refused, and the resident reported never receiving a shower since admission. Staff and DON confirmed the absence of required documentation.
A resident in need of pain management did not receive safe and appropriate pain control, as the facility did not adequately address the resident's pain according to their requirements.
The facility failed to implement proper infection control measures for a resident suspected of having C-Diff, did not follow infection control standards during medication administration for three residents, and did not maintain laundry practices to prevent infection spread. A resident with diarrhea was not placed on isolation precautions, and staff were observed handling medications and soiled linens without appropriate barriers or PPE, leading to potential contamination.
A resident, who was cognitively intact, did not receive showers as per their preference and schedule, leading to dissatisfaction. The resident expressed a desire for showers twice a week, but records showed missed showers on scheduled days. Staff documentation inaccurately reflected the care provided, as the resident reported not receiving a bed bath as claimed by a CNA.
The facility failed to notify a resident's family in a timely manner about the end of Medicare Part A coverage. The resident's Medicare Part A skilled services began on 11/25/24, with the last covered day being 12/16/24. The SNF Advanced Beneficiary Notice of Non-Coverage and the Notice of Medicare Non-Coverage were signed by the resident's son on the last day of coverage. The Social Service Director admitted that the family should have been notified at least two days prior and could not find documentation of prior notification.
The facility failed to ensure personal privacy for three residents due to bedroom doors not closing completely, as beds were obstructing the doorways. One resident reported the issue had persisted since admission, and similar problems were observed in the rooms of two other residents. The DON and Executive Director were informed, and it was noted that bed bumpers were causing the obstruction.
The facility failed to ensure accurate MDS assessments, resulting in multiple deficiencies. A resident with hemiplegia had an undocumented contracture, while two residents were inaccurately reported as not using opioids despite prescriptions. Another resident's MDS incorrectly stated a facility death, and a resident was wrongly documented as using anticoagulants. The MDS coordinator acknowledged these errors.
A facility failed to complete a PASARR Level II in a timely manner for a resident with a mental disorder or intellectual disability. The initial Level II submission was closed due to an incomplete signature, and it was not resubmitted with the necessary information, leading to a compliance deficiency.
The facility failed to complete baseline care plans within 48 hours for three residents. One resident's care plan was delayed by eight days, while two others had no care plans located. Staff interviews revealed confusion about the location of these documents, and efforts to find them were unsuccessful.
A resident with limited hand function due to diabetes was not consistently assisted with getting out of bed or having his teeth brushed, despite his requests. The facility failed to provide necessary ADL support, as observed by surveyors, leading to the resident remaining in bed and with unbrushed teeth. Staff inconsistencies and care plan updates only occurred after surveyor intervention.
Two residents in a facility were not adequately encouraged or assisted to participate in activities, despite their care plans indicating preferences for social engagement, music, and religious services. Observations showed the residents spending most of their time in their rooms, with one resident expressing a desire for more engagement and the other wanting to attend activities but not being assisted. The facility's documentation and communication regarding activity participation were insufficient, leading to a deficiency in meeting the residents' needs.
A facility failed to follow physician's orders for several residents, leading to medication administration errors and testing oversight. A resident with hypertension received incorrect doses of Metoprolol and Midodrine, while another with hypothyroidism did not receive the correct dosage of Levothyroxine. A third resident's methocarbamol was not administered at the correct intervals, and a stool sample for C-Diff testing was not collected for another resident.
A resident with a suprapubic urinary catheter did not receive a timely urology appointment as ordered by a physician. Despite observations of cloudy urine, indicating a potential issue, the facility failed to schedule the consult due to a breakdown in communication and process. Staff responsible for making appointments did not have the necessary information and did not take steps to obtain it, resulting in the deficiency.
A facility failed to maintain the nutritional status of a dialysis resident by not ensuring the ordered Nepro supplement was consumed. The resident, at risk for malnutrition, reported not consuming the supplement due to stomach upset and dissatisfaction with the facility's food. The RD was unaware of the issue and had not followed up on the resident's food preferences.
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in oxygen therapy management. One resident's nebulizer mask was improperly stored, another used oxygen without a physician's order, and a third received oxygen at a higher rate than prescribed. These actions demonstrate a failure to follow physician orders and ensure proper respiratory care.
A resident with an arterial stasis ulcer and depression was prescribed tramadol for pain management. However, the facility failed to administer the medication as ordered, providing only one tablet instead of the prescribed two, leading to inadequate pain relief. The resident reported significant pain, and the issue was confirmed by a review of the medication monitoring control record.
A facility failed to provide appropriate dialysis care for a resident by not completing required communication forms and not implementing dietitian recommendations in a timely manner. The resident's dialysis communication forms were missing on several dates, and medication adjustments recommended by the dietitian were delayed or not executed.
A facility failed to individualize the care plan for a resident with PTSD, who was cognitively intact and independent in daily activities. The care plan lacked specific details about the resident's trauma, behaviors, or triggers. The resident identified crowds as a trigger, and the Social Service Director acknowledged the care plan was generic and not tailored to the resident's personal experiences.
The facility failed to provide sufficient staffing, resulting in delays in uploading physician progress notes for a resident with diarrhea and scheduling a urology consult for another resident with a suprapubic catheter. The medical records staff was overwhelmed due to increased census and high turnover, while the Medical Transportation Coordinator was unable to schedule the consult due to incomplete information and multiple responsibilities.
The facility failed to document narcotic removal in the MARs for three residents, leading to discrepancies in medication records. A resident had missing entries for Tramadol removal on specific dates, while another resident's records showed missing documentation for Tramadol removal at two different times. Additionally, a third resident's records revealed missing documentation for Lorazepam removal on two consecutive days. These issues were identified during a medication storage review, and the DON was informed of the discrepancies.
A facility failed to monitor side effects and behaviors for a resident on psychotropic medications. The resident, with multiple mental health diagnoses, was not placed back on behavioral monitoring after returning from hospitalizations. Interviews with an LPN and the Regional Nurse Consultant confirmed the lack of documentation and awareness of monitoring procedures.
An LPN administered medications incorrectly to a resident, resulting in a medication error rate of 14.81%. The resident received incorrect dosages of eye drops and docusate sodium, was given hydralazine without meeting the required blood pressure parameters, and did not receive the prescribed Senna tablets due to unavailability on the medication cart.
The facility failed to properly store medications for two residents. An LPN left artificial tears unattended on a medication cart, and another resident had a pill cup with medications left on his bedside table. The resident reported receiving an incorrect dosage of Levothyroxine. These incidents highlight issues with medication security and administration.
The facility failed to maintain complete medical records for several residents, with missing physician progress notes and unscanned documentation. A resident's record was incomplete, with outdated physician notes, while others had missing or unscanned visit documentation. Additionally, a dietitian consult for a resident receiving tube feeding was not documented, despite discussions with a nurse practitioner about fluid adjustments.
The facility failed to maintain portable fire extinguishers according to NFPA 101 standards. During a facility tour, it was observed that several fire extinguishers were installed with the top of the handle above 60 inches from the floor, which does not comply with accessibility and safety standards. The Maintenance Director confirmed these findings.
A facility failed to maintain corridor doors according to NFPA 101 standards, as observed during a tour where the door to room 47 could not close due to rubbing against the floor. This deficiency was confirmed by the Maintenance Director and discussed in an exit conference.
A long-term care facility failed to ensure proper medication administration for several residents, as staff did not document the administration of prescribed medications. This issue affected residents with various medical conditions, including heart disease, diabetes, and neurological disorders, following an evacuation due to a storm.
The facility failed to provide and document necessary care for two residents, including tracheostomy care, wound dressing changes, and PICC line maintenance. One resident with complex medical needs missed multiple treatments, while another had outdated PICC line dressing and missed skin checks. The DON noted that records were initially taken by another facility's staff but later accessed to ensure care.
A resident with multiple medical conditions, including a persistent vegetative state and acute respiratory failure, was found with a significant lack of oral hygiene care. The resident, who required total care, was observed with a copious amount of dry yellowish-brown crusty substance in her mouth and lips. A nurse, newly on shift, was unaware of the care provided to the resident.
A resident with serious medical conditions did not receive proper PICC line care and IV medications as required. The facility's staff failed to change the PICC line dressing weekly and did not document the administration of prescribed IV medications for several doses. The resident's MAR indicated missing doses and unavailable medications, contributing to the deficiency.
A resident with end-stage renal disease did not receive dialysis for seven days due to communication failures between the LTC facility and the dialysis provider. Despite having physician orders, the necessary documentation was not sent, and staff were unaware of the resident's dialysis needs. This resulted in the resident being transferred to a hospital with critically high potassium levels, where they later passed away.
A resident with end-stage renal disease did not receive dialysis for seven days due to communication failures between the facility and the dialysis provider. The resident, who had multiple health conditions, was admitted with specific orders for hemodialysis but was not dialyzed, leading to severe health complications and eventual death. The facility lacked a policy for managing new admissions requiring dialysis, contributing to the oversight.
A resident with end-stage renal disease did not receive dialysis for seven days due to communication failures between the LTC facility and the dialysis provider. Despite having a physician's order for dialysis, the resident's condition deteriorated, leading to an emergency transfer to the hospital, where they were diagnosed with severe hyperkalemia, uremia, and sepsis. The resident passed away shortly after the transfer.
Two residents reported that their preferences for larger food portions were not honored after a change in facility ownership. The facility's policy now requires a medical reason for providing larger portions, as confirmed by the CDM and Dietitian. This change has led to dissatisfaction among residents who previously received larger portions.
A resident reported being served expired chocolate milk on multiple occasions, confirmed by observations of expired milk in the facility's refrigerator. Despite the issue being raised in a Resident Council meeting, the facility failed to implement a plan to prevent recurrence, as confirmed by the Certified Dietary Manager.
A resident with severe cognitive impairment and a BIMS score of 0, identified as at risk for elopement, exited the facility undetected and was found 1.4 miles away by police. The facility's Policies and Procedures required daily checks of the wander monitoring system, but the resident exited through emergency exit doors in a unit under construction that were unlocked or disalarmed. The facility lacked security cameras covering these doors, and staff interviews revealed gaps in monitoring and response. The Assistant Maintenance Director confirmed issues with the wanderguard sensors, as the door could be opened without alarming. The resident was exposed to hazards such as a high-speed 4-lane road during the unsupervised walk.
A resident with severe cognitive impairment exhibited exit-seeking and wandering behaviors, leading to a room change and the implementation of an electronic monitoring device. However, a comprehensive assessment inaccurately documented that the resident did not exhibit wandering behaviors.
Failure to Follow Anticoagulation Orders and Accurate Medication Documentation
Penalty
Summary
The deficiency involves failures in anticoagulation management and medication administration/documentation for two residents. For one resident with a history of valve replacement, the physician ordered warfarin (5 mg every other day) and associated PT/INR and CMP labs. Initial PT/INR labs were reported as invalid, and the physician subsequently ordered warfarin to be held pending INR results. When INR results were later received, the physician adjusted the warfarin dose to 2.5 mg on one day and 5 mg daily on subsequent days. The MAR showed nurses initialed administration of 5 mg doses on multiple days, even though the order to hold warfarin remained in effect until a later date. Nursing documentation reflected elevated INRs of 3.38 on two days and a critically elevated INR of 9.12 on another day, yet warfarin was still administered and there was no evidence the physician was contacted for guidance when these elevated INRs were obtained. When the INR was critically elevated at 17.63, the physician ordered vitamin K 10 mg injection and daily INR labs for two days, but there was no evidence the ordered labs were drawn or that staff followed up with the lab; labs were not completed until several days later, by which time the resident’s condition had deteriorated, including becoming nonresponsive and not eating, and the resident was transferred to the hospital. Pharmacy records showed 21 warfarin 5 mg tablets were dispensed and 20 were returned at discharge, despite MAR entries indicating four doses (one 2.5 mg and three 5 mg) had been administered, and the DON confirmed there were no warfarin tablets taken from the emergency kit and no other residents on warfarin. For a second resident, a medication pass was observed with a licensed nurse who prepared and administered six oral medications, which the surveyor verified by name and dose. The nurse confirmed that no additional medications were to be given at that time other than insulin, which was held due to a blood sugar of 109. However, on the MAR, the nurse documented that she had also administered polyethylene glycol 3350 powder, 17 g twice daily, even though this medication was not given during the observed pass. When questioned, the nurse acknowledged she had signed for administering the polyethylene glycol despite not having given it. She then searched the medication cart, found no polyethylene glycol, went to the supply room to retrieve a bottle, and administered the medication after the fact. The nurse stated she must have obtained the medication from another cart when she administered the morning dose, since none was available on the current cart at the time of the evening pass.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the Statement of Deficiencies; this plan of correction is prepared and/or executed solely because it is required (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? A. On [R] resident #1 was discharged from facility to Lawnwood Regional Medical Center. B. On [R] Physician was notified of prior events and current conditions for resident discharged to Lawnwood Regional Medical Center on [R] . No additional residents were affected at this time. C. On [R] , comprehensive medication and lab review for resident #1 was completed to ensure all physician orders and current and being followed; resident transferred to hospital prior to additional interventions being implemented. D. As of [R] , the licensed nursing staff identified in the deficient practice are no longer employed by the facility. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: A. On [R], the Director of Nursing/Designee identified and reviewed current residents receiving [R]. The review included verification of current physician orders, review of [R] INR results and therapeutic ranges, confirmation of timely laboratory draws, and verification of appropriate medication and documentation. At the time of the review, there were no residents in the facility receiving [R] [R] therapies were reviewed. Any discrepancies identified during the review were immediately corrected, including physician notification and clarification orders. (3) What measures will be put into place or what systematic changes you will make to ensure A. By [R], the facility implemented system changes, including the establishment of an [R] Management Protocol outlining INR critical value parameters, required interventions for elevated INR levels, and mandatory physician notification guidelines. A Lab Tracking Log was also implemented to ensure all ordered laboratory tests are completed as scheduled, reviewed in a timely manner, and escalated appropriately when not obtained. In addition, High-Risk Medication Audits [R] tool for [R] monitor compliance and medication safety practices. Education was completed with licensed nursing staff regarding the administration, monitoring, [R] management of [R] including therapeutic INR ranges, timely physician notification, documentation requirements, and appropriate interventions for abnormal lab values. B. By [R], Licensed Nursing Staff will have been educated by Director of Nursing/Designee on the components of F684 with an emphasis on medication administration safety, documentation accuracy, and appropriate clinical decision-making and escalation protocols. C. Newly hired licensed nursing staff will receive education by the Director of Clinical/Designee on the components of F684 with an emphasis on medication administration safety, documentation accuracy, and appropriate clinical decision-making and escalation protocols. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: A. The Director of Nursing/Designee will conduct audits on 5 residents on weekly x 4 weeks, then biweekly x 4 weeks, then monthly x 1 month. Audits will include medication administration accuracy, lab completion and follow up, physician notification compliance. The findings of these quality monitoring's to be reported to the quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Hold Warfarin and Complete Ordered INR Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s anticoagulation drug regimen was free from unnecessary drugs and was adequately monitored. The resident was admitted on warfarin for a mechanical heart valve, with physician orders for 5 mg dosing and ongoing PT/INR monitoring. Laboratory results showed critically elevated PT/INR values, including a PT of 94.9 seconds with an INR of 9.12 and later a PT of 180 seconds with an INR of 17.63. Despite these elevated results, the clinical record shows that warfarin was administered, and there is no evidence that nursing staff consistently contacted the physician for guidance prior to giving the medication when the INR was elevated. Physician orders were in place to hold warfarin pending INR results and later to adjust the dose to 2.5 mg on one day and resume 5 mg daily thereafter, with associated INR monitoring. The Medication Administration Record indicates that nurses initialed administration of 2.5 mg on the ordered day and 5 mg on subsequent days, including days when the INR was documented as 3.38 and 9.12. The record further shows that warfarin 5 mg was documented as administered during a period when the order indicated the medication was on hold. There is no documentation that the physician was notified when the INR values were elevated prior to these administrations. After the INR reached a critically high value of 17.63, the physician ordered vitamin K and daily PT/INR labs for two days; however, the lab results provide no evidence that these ordered labs were drawn on the specified days. The next PT/INR was not completed until a later date, by which time the resident had experienced a change in condition, including being nonresponsive and not eating. Progress notes from an advanced registered nurse practitioner and another practitioner describe the resident as drowsy, less responsive, and exhibiting an overall decline. The DON confirmed in interview that the ordered labs were not drawn on the specified days and that there is no evidence nurses contacted the physician before administering warfarin when the INR was elevated.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the Statement of Deficiencies. This plan of correction is prepared and/or executed solely because it is required (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? A. On [R] , resident #1 was discharged from facility to Lawnwood Regional Medical Center. B. As of [R] , there are no residents on [R] . No additional residents were identified as negatively [R] . (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; A. On [R] , the Director of Nursing/Designee identified and reviewed current residents receiving [R] . The review included verification of current physician orders, review of [R] INR results and therapeutic ranges, confirmation of timely laboratory draws, and verification of appropriate medication and documentation. At the time of review, there were no residents in the facility receiving [R] , however, all other [R] therapies were reviewed. Any discrepancies identified during the review were immediately corrected, including physician notification and clarification of orders. (2) (3) What measures will be put into place or what systematic changes you will make to ensure A. By [R] , License Nursing staff will have been educated by the Director of Nursing/Designee on the components of F757, including the use of the [R] management protocol, documentation of indication and monitoring, appropriate response to laboratory results, and timely physician notification, with an emphasis on avoidance of unnecessary drugs and compliance with monitoring requirements for [R] .B. Newly hired license nursing staff will receive education by the Director of Nursing/Designee on the components of F757, including the use of the management protocol, documentation standards, critical lab value reporting and escalation processes, and physician communication expectations during orientation as part of the facility's systematic changes.(3) (4) How the corrective action(s) will be monitored to ensure the practice will not recur, ie., what quality assurance program will be put in place:A. The Director of Nursing/designee will conduct [R] monitoring audits weekly for 4 weeks, then biweekly for 4 weeks, and monthly x 1 month. Audits will review appropriate drug use, compliance with laboratory monitoring, timely physician notification, and accuracy of documentation.The findings of these quality monitoring is to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Follow Anticoagulant Orders and Accurate Medication Administration Practices
Penalty
Summary
The deficiency involves failure to follow physician orders and accepted standards of practice for anticoagulant management and medication administration documentation for two residents. One resident was admitted with a history that included valve replacement and was prescribed an anticoagulant 5 mg by mouth every other day, with INR labs to be drawn. A subsequent physician order directed that the anticoagulant be held pending INR results, and later an order was given for the resident to receive 5 mg daily and to resume the medication. The MAR showed nurses initialed administration of 2.5 mg on one date and 5 mg on three dates, even though the physician’s order indicated the 5 mg dose was on hold on two of those dates. Nursing documentation reflected elevated INRs of 3.38 and then 9.12, yet the 5 mg dose was still administered when the INR was 9.12, and there was no evidence that the physician was contacted for guidance when the INRs were elevated. Further review of lab results for this resident showed critically elevated coagulation values, including a prothrombin time of 94.9 seconds with an INR of 9.12, and later a prothrombin time of 180 seconds with an INR of 17.63. When the INR was critically elevated at 17.63, the physician ordered vitamin K 10 mg injection and INR labs to be drawn for two days. The record did not show that these ordered labs were drawn as prescribed, nor that staff followed up with the lab to ensure completion; the labs were not completed until a later date, by which time the resident’s condition had changed and deteriorated, requiring transfer to the hospital for further evaluation. Pharmacy dispensing records showed that 21 tablets of the 5 mg anticoagulant were dispensed and 20 tablets were returned at discharge, while the MAR contained four documented doses, raising questions about whether the medication was actually administered as charted. The DON confirmed that the ordered labs were not drawn on the specified days and that there was no evidence nurses contacted the physician before administering the anticoagulant when the INR was elevated. A second deficiency involved inaccurate medication administration and documentation for another resident. During an observed medication pass, a licensed nurse prepared and administered six oral medications, which were verified by the surveyor, and confirmed that no additional medications were to be given at that time other than an insulin dose that was held due to a blood glucose of 109. However, on the MAR, the nurse documented that she had also administered polyethylene glycol 3350 powder, 17 g by mouth twice daily for constipation, even though this medication had not been given during the observed pass. When questioned, the nurse acknowledged she had not administered the polyethylene glycol but had signed for it, then searched the medication cart, found none available, went to the supply room to retrieve a bottle, and subsequently administered the dose. She stated she must have retrieved the medication from another cart previously, despite its absence on the current cart at the time of the observation.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the Statement of Deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? A. On [R] resident #1 was discharged from facility to Lawnwood Regional Medical Center. B. On [R] Physician was notified of prior events and current conditions for resident discharged to Lawnwood Regional Medical Center on [R]. No additional residents were affected at this time. C. On [R], comprehensive medication and lab review for resident #1 was completed to ensure all physician orders are current and being followed; resident transferred to hospital prior to additional interventions being implemented. D. As of [R], the licensed nursing staff identified in the deficient practice are no longer employed by the facility. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: A. On [R], the Director of Nursing/Designee identified and reviewed current residents receiving [R]. The review included [R] verification of current physician orders, review of [R]/INR results and therapeutic ranges, confirmation of timely laboratory draws, and verification of appropriate medication and documentation. At the time of the review, there were no residents in the facility receiving [R]/ however, all other [R] therapies were reviewed. Any discrepancies identified during the review were immediately corrected, including physician notification and clarification orders. (3) What measures will be put into place or what systematic changes you will make to ensure A. By [R], the facility implemented system changes, including the establishment of an [R] Management Protocol outlining INR critical value parameters, required interventions for elevated INR levels, and mandatory physician notification guidelines. A Lab Tracking Log was also implemented to ensure all ordered laboratory tests are completed as scheduled, reviewed in a timely manner, and escalated appropriately when not obtained. In addition, High-Risk Medication Audits Tool for [R] was put into place to monitor compliance and medication safety practices. Education was completed with licensed nursing staff regarding the administration, monitoring, management of [R]/ including therapeutic INR ranges, timely physician notification, documentation requirements, and appropriate interventions for abnormal lab values. B. By [R], Licensed Nursing Staff will have been educated by Director of Nursing/Designee on the components of N0054 with an emphasis on medication administration safety, documentation accuracy, and appropriate clinical decision-making and escalation protocols. C. Newly hired licensed nursing staff will receive education by the Director of Clinical/Designed on the components of N0054 with an emphasis on medication administration safety, documentation accuracy, and appropriate clinical decision-making and escalation protocols. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: (A) The Director of Nursing/Designee will conduct audits on 5 residents on [R] weekly x 4 weeks, then biweekly x 4 weeks, then monthly x 1 month. Audits will include medication administration accuracy, lab completion and follow up, physician notification compliance. The findings of these quality monitoring's to be reported to the quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Follow Anticoagulation Orders and INR Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident on anticoagulation therapy received necessary treatment and care in accordance with professional standards, including ordered monitoring, medication administration, and accurate documentation. The resident was admitted with a history of valve replacement and was prescribed a specific anticoagulant dosage regimen and associated lab monitoring (INR and CMP) beginning on designated dates. Initial INR labs were reported as invalid, and subsequent orders included holding the anticoagulant pending INR results, then resuming at adjusted doses based on those results. The MAR shows nurses initialed doses of 2.5 mg and 5 mg as administered on multiple days. Documentation reflects that on one date the resident’s INR was 3.38 and on a later date the INR was 9.12, yet the 5 mg dose was still administered despite the elevated INR, and there is no evidence that the physician was contacted at those times for guidance regarding whether to administer the medication. When the resident’s INR later reached a critically elevated level of 17.63, the physician ordered vitamin K 10 mg injection and daily INR labs for two days. Review of lab results and records shows no evidence that these ordered labs were drawn on the specified days, nor that staff followed up with the lab to ensure the orders were carried out; labs were not completed until several days later. By that time, the resident had a documented change in condition, becoming nonresponsive and not eating, which led to additional interventions and eventual transfer to the hospital. The DON confirmed that the ordered labs were not drawn on the specified days, that there was no evidence nurses contacted the physician before administering the anticoagulant when the INR was elevated, and that pharmacy records showed 20 of 21 dispensed 5 mg tablets were returned upon discharge despite MAR entries indicating four doses had been given. The DON also reported that no tablets were removed from the emergency drug kit and that the facility had not had any residents on this medication in over a year.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the Statement of Deficiencies. this plan of correction is prepared and/or executed solely because it is required (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? A. On [R] , resident #1 was discharged from facility to Lawnwood Regional Medical Center. B. As of [R] , there are no residents on [R] . No additional residents were identified as negatively [R] . (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: A. On [R] , the Director of Nursing/Designee identified and reviewed current residents receiving [R] . the review included verification of current physician orders, review of INR results and therapeutic ranges, confirmation of timely laboratory draws, and verification of appropriate medication and documentation. At the time of review, there were no residents in the facility receiving [R] ; however, all other [R] therapies were reviewed. Any discrepancies identified during the review were immediately corrected, including physician notification and clarification of orders. (3) What measures will be put into place or what systematic changes you will make to ensure A. By [R] , License Nursing staff will have been educated by the Director of Nursing/Designee on the components of N0201, including the use of the [R] management protocol, documentation of indication and monitoring, appropriate response to laboratory results, and timely physician notification, with an emphasis on avoidance of unnecessary drugs and compliance with monitoring requirements for [R] B. Newly hired license nursing staff will receive education by the Director of Nursing/Designee on the components of N0201, including the use of the [R] management protocol, documentation standards, critical lab value reporting and escalation processes, and physician communication expectations during orientation as part of the facility's systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, ie., what quality assurance program will be put in place: A. The Director of Nursing/designee will conduct [R] monitoring audits weekly for 4 weeks, then biweekly for 4 weeks, and monthly x 1 month. Audits will review appropriate drug use, compliance with laboratory monitoring, timely physician notification, and accuracy of documentation. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Follow Anticoagulation Orders and Accurate Medication Administration/Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders and professional standards for two residents. For one resident with a prosthetic heart valve, the physician ordered warfarin therapy with associated PT/INR, CBC with differential, and CMP monitoring. An initial PT/INR drawn on 02/07/26 was invalid, and the physician ordered warfarin to be held pending results. After new lab results were received on 02/08/26, the physician adjusted the warfarin dose and ordered resumption of 5 mg daily. The MAR showed nursing initials indicating administration of warfarin doses on multiple days, even though the physician’s orders reflected that warfarin 5 mg was on hold from 02/07/26 to 02/10/26 and again from 02/13/26 to 02/16/26. Nursing documentation showed that the resident’s INR was 3.38 on 02/09/26 and 02/10/26, and on 02/11/26 the INR was documented as 9.12, yet warfarin 5 mg was still administered and there was no evidence that the physician was contacted regarding these elevated INRs. On 02/13/26, when the INR was critically elevated at 17.63, the physician ordered vitamin K 10 mg IM and PT/INR labs for two days. The record lacked evidence that these ordered labs were drawn on 02/14/26 and 02/15/26 or that staff followed up with the lab to ensure completion; labs were not obtained until 02/16/26, by which time the resident had a change in condition, becoming nonresponsive and not eating, and was transferred to the hospital. Pharmacy records showed that 21 tablets of warfarin 5 mg were dispensed and 20 were returned at discharge, despite MAR entries indicating four doses of warfarin (one 2.5 mg and three 5 mg) had been administered, and the DON confirmed there were no warfarin tablets taken from the emergency kit and no other residents on warfarin. For a second resident, a medication pass observation revealed that a nurse prepared and administered six oral medications, which were verified by the surveyor, and held Lantus due to a blood sugar of 109. During subsequent MAR review, the nurse had documented administration of polyethylene glycol 3350 powder, ordered twice daily for constipation, even though this medication had not been given during the observed pass. When interviewed, the nurse acknowledged that she had signed for administering the polyethylene glycol without actually giving it, then searched the medication cart, found none available, obtained a bottle from the supply room, and administered the dose after the discrepancy was identified. The nurse also stated that she must have retrieved the medication from another cart for the morning dose because none was present on the observed cart.
Failure to Appropriately Manage Warfarin Therapy and Elevated INR Results
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s warfarin regimen was free from unnecessary drugs and appropriately managed in response to elevated INR values. The resident was admitted with a diagnosis including a prosthetic heart valve and was prescribed warfarin 5 mg with PT/INR monitoring. On one occasion, PT/INR labs drawn were noted as invalid, and subsequent PT/INR results showed markedly elevated values, including a prothrombin time of 94.9 seconds with an INR of 9.12, and later a prothrombin time of 180 seconds with an INR of 17.63. Despite these elevated results, the clinical record shows that warfarin 5 mg was administered on multiple days, including a day when the INR was documented as 9.12, and there is no evidence that the physician was contacted prior to administering warfarin in the presence of these elevated INRs. The record further shows inconsistencies between physician orders to hold warfarin and the medication administration record. The physician ordered warfarin 5 mg every other day beginning on a specified date, with PT/INR monitoring, and then ordered warfarin to be held pending PT/INR results. After PT/INR results were received, the physician adjusted the dose to 2.5 mg on one day and then to resume 5 mg daily on subsequent days. However, the MAR reflects that warfarin 2.5 mg was administered on the day ordered and warfarin 5 mg was administered on several days, even though the physician orders indicate warfarin 5 mg was to be on hold during some of those dates. Nursing documentation also shows that warfarin was administered when the INR was 3.38 and again when the INR was 9.12, without documented evidence of physician notification or guidance before administration. When the INR was later noted as critically elevated at 17.63, the physician was contacted and ordered vitamin K and daily PT/INR labs for two days. The record review revealed that these ordered PT/INR labs were not drawn on the specified days and were not completed until a later date. There is no evidence that staff followed up with the lab to ensure the ordered tests were performed as prescribed. By the time the labs were completed, the resident had experienced a change in condition, described as lethargic, nonresponsive, and not eating, and required further evaluation and eventual transfer to the hospital. The DON confirmed in interview that the labs were not drawn as ordered on the two days, that there was no evidence nurses contacted the physician before administering warfarin when the INR was elevated, and that the nurse who administered warfarin with an INR of 9.12 and other involved nurses were no longer available or no longer worked at the facility.
Failure to Provide and Document Scheduled Showers for Dependent Resident
Penalty
Summary
A deficiency was identified when the facility failed to provide and document shower services for a resident with cancer who was admitted with functional limitations in both upper and lower extremities. The resident was assessed as cognitively intact and required substantial to maximal assistance with showering, bathing, dressing, and personal hygiene, and was dependent on staff for footwear. According to the resident's care plan, showers were scheduled three times a week during the day shift. However, a review of Certified Nursing Assistant (CNA) task records over a 30-day period revealed no documented evidence that showers were provided on multiple scheduled dates. During interviews, the resident stated he had never received a shower since admission and did not refuse showers when offered, only receiving bed baths. Staff confirmed that showers or refusals should be documented in the shower books, but a review of these records with both a CNA and the Interim DON found no documentation of showers or refusals for the resident. The lack of documentation and the resident's statements indicated that the facility failed to provide the ordered care and services as required.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The facility failed to ensure that the resident's pain was properly addressed according to their needs.
Infection Control Deficiencies in Resident Care and Laundry Management
Penalty
Summary
The facility failed to implement appropriate transmission-based precautions for a resident suspected of having C-Diff, a contagious intestinal infection. Resident #83, who was cognitively intact and dependent on activities of daily living, was admitted to the facility and later developed diarrhea. Despite being care planned for antibiotic therapy and having a change in condition noted, the resident was not placed on contact or special isolation precautions to prevent the spread of the suspected infection. Additionally, the resident's roommate also experienced diarrhea, further highlighting the need for proper infection control measures. During medication administration observations, several lapses in infection control standards were noted. For Resident #193, an LPN placed a box of eye drops directly on the resident's chair without using a tray or barrier, potentially contaminating the medication. Similarly, for Resident #10, an RN placed a plastic bag containing eye drops on the resident's over-the-bed table without a barrier, and then returned the contaminated bag to the medication cart. Furthermore, for Resident #65, an RN administered a transdermal patch without wearing gloves, contrary to the facility's policy, and handled medication pills directly with her hands before placing them in a medication cup. The facility also failed to maintain laundry practices that prevent the spread of infection. Laundry staff were observed handling overflowing bins of soiled linens without appropriate personal protective equipment, such as gloves, and the bins were not properly covered. Additionally, the laundry area was found to have cleanliness issues, including a dried substance inside a dryer, a stained handwashing sink, and debris around the washing machines. These observations indicate a lack of adherence to infection control policies and procedures in the facility's laundry management.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not providing showers as per the resident's schedule and request. Resident #2, who was cognitively intact with a BIMS score of 15, expressed a preference for receiving showers twice a week. However, the facility's records showed that the resident did not receive showers on the scheduled dates of 02/25/25 and 03/01/25, and the last documented shower was on 03/18/25. The care plan indicated that the resident required maximum assistance with bathing due to an ADL self-care performance deficit related to disease process, impaired balance, and weakness. Interviews revealed discrepancies in the documentation and the actual care provided. Resident #2 reported not receiving showers as often as desired and stated that he had communicated his preferences to the staff without any changes being made. Staff B, a CNA, claimed to have provided a bed bath, which she documented as a shower, but the resident contradicted this by stating he had not received a bed bath. This inconsistency highlights a failure in communication and documentation, leading to the resident's dissatisfaction with the care provided.
Failure to Timely Notify Family of Medicare Coverage Ending
Penalty
Summary
The facility failed to notify the family of a resident in a timely manner regarding the end of Medicare Part A coverage. The review of the SNF Beneficiary Protection Notification for the resident showed that Medicare Part A skilled services began on 11/25/24 and the last covered day was 12/16/24, as initiated by the facility. The SNF Advanced Beneficiary Notice of Non-Coverage and the Notice of Medicare Non-Coverage were signed by the resident's son on 12/16/24, which was the last day of covered services. During an interview, the Social Service Director acknowledged that the resident or family should have been notified at least two days before the coverage ended and could not find any documentation indicating that the family was notified before 12/16/24.
Privacy Deficiency Due to Bedroom Door Obstructions
Penalty
Summary
The facility failed to provide personal privacy for three residents due to issues with bedroom doors not closing completely. Observations revealed that the main door to the bedroom of one resident could not close because the bed was protruding into the door space, and the privacy curtain was knotted, preventing privacy during personal care. This resident reported that the door had been in this condition since admission. The Director of Nursing and the Executive Director were informed of the issue, and it was noted that bed bumpers were preventing the bed from being positioned closer to the wall. Similar issues were observed in the rooms of two other residents, where the beds also obstructed the doorways, preventing them from closing. These deficiencies were identified during observations and interviews conducted by surveyors.
Inaccurate MDS Assessments Lead to Multiple Deficiencies
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for several residents, leading to multiple deficiencies. Resident #5, who was admitted with hemiplegia, exhibited a contracture of the left hand, which was not documented in the MDS assessment. Despite observations confirming the contracture, the MDS coordinator acknowledged the lack of documentation. Resident #107 and Resident #64 were both prescribed opioids, yet their MDS assessments inaccurately reflected no opioid use. The MDS coordinator confirmed these inaccuracies upon review. Resident #139 was transferred to a hospital due to respiratory failure, but the MDS assessment incorrectly documented the resident as deceased in the facility. The MDS coordinator and the Regional MDS nurse provided conflicting explanations, with no documentation supporting the facility death status. Additionally, Resident #32's MDS assessment inaccurately indicated anticoagulant use, despite no evidence of such medication in the resident's records. The MDS coordinator acknowledged the error after reviewing the records.
Failure to Timely Complete PASARR Level II
Penalty
Summary
The facility failed to obtain a PASARR Level II in a timely manner for a resident who was admitted with a mental disorder or intellectual disability. The resident was admitted to the facility, and a PASARR Level I screening indicated that a Level II assessment was necessary. Although the Level II was initially submitted, it was closed due to an incomplete signature for the resident. The Regional Social Services Director confirmed that the Level II had not been resubmitted with the missing information, resulting in a deficiency in the facility's compliance with PASARR requirements.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to ensure that baseline care plans were completed within 48 hours of admission for three residents. Resident #32 was admitted to the facility and readmitted from the hospital, but the baseline care plan was not completed until eight days after admission. For Resident #103 and Resident #117, the facility was unable to locate any baseline care plans, indicating that they were not completed as required. Interviews with facility staff revealed confusion and miscommunication regarding the location of the baseline care plans. The Social Service Director and the MDS Coordinator provided conflicting information about where the care plans were stored, with the MDS Coordinator eventually admitting that she misunderstood the question and was unable to locate the care plans for Resident #103 and Resident #117. Despite efforts by the Regional Nurse Consultant to find the missing documents, they were not located, indicating a failure in the facility's process for managing and storing baseline care plans.
Failure to Assist Resident with ADLs and Dental Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident, specifically in the areas of dental care and mobility. Observations revealed that the resident was consistently left in bed without being offered the opportunity to get up, despite his requests to do so. The resident, who has been in the facility since October 2024, reported that he had only been out of bed twice. Additionally, the resident's teeth were observed to have food caked between them, and he stated that his teeth were not being brushed by the staff, despite his inability to do so himself due to limited hand function caused by diabetes. The resident's care plan indicated that he required substantial assistance for oral hygiene and mobility, yet these needs were not being met. Interviews with staff revealed inconsistencies in the care provided. A CNA admitted to only getting the resident out of bed on specific days and not offering to do so on others. The resident expressed frustration with this arrangement and disagreed with the CNA's claim that she offered to brush his teeth. Furthermore, there was a discrepancy regarding the storage of the resident's wheelchair, with conflicting statements from the CNA and the occupational therapist. The resident's care plan was updated only after the surveyor's intervention, indicating a lack of proactive care management. The resident expressed happiness when finally assisted out of bed and having his teeth brushed, highlighting the deficiency in consistent care provision prior to the surveyor's involvement.
Failure to Facilitate Resident Participation in Activities
Penalty
Summary
The facility failed to encourage and assist two residents, identified as Resident #32 and Resident #243, to participate in activities, as observed and documented by surveyors. Resident #32, who has a history of aortic stenosis, type 2 diabetes, pulmonary disease, heart failure, reflux disease, hydronephrosis, anemia, restless leg syndrome, and kidney disease, was observed multiple times in his bed either playing on his phone or doing nothing. Despite his care plan indicating a preference for activities such as watching television, playing the harmonica, listening to classical music, and attending religious services, the facility did not facilitate his participation in these activities. Interviews revealed that Resident #32 expressed a desire for more engagement, including having a chaplain visit him, but reported that the facility did not assist him in attending activities or provide in-room activities. Resident #243, who has a history of acute myocardial infarction, heart failure, kidney failure, hypotension, anemia, muscle weakness, dysphagia, and atrial flutter, was similarly observed spending most of his time in his room, either eating meals or lying in bed. His care plan highlighted his interest in social activities, music, news, and religious services, yet the facility did not adequately support his participation in these activities. Interviews with Resident #243 indicated that he wanted to attend activities, including church services, but was not assisted in getting out of bed to participate. The Community Life Director and Activities Assistant failed to document or facilitate his involvement in activities, despite his expressed interest. The facility's documentation and communication regarding the residents' activity preferences and participation were inadequate. The Community Life Director admitted to recording activity participation but was unable to retrieve the records, and the Activities Assistant did not actively engage with Resident #243 to encourage his participation in activities. The surveyor's observations and interviews highlighted a lack of proactive measures by the facility to ensure that the residents' activity preferences and needs were met, resulting in a deficiency in providing adequate activity engagement for the residents.
Medication Administration Errors and Testing Oversight
Penalty
Summary
The facility failed to adhere to physician's orders for several residents, leading to medication administration errors. Resident #103, diagnosed with Essential Hypertension, had specific blood pressure parameters for administering Metoprolol and Midodrine. However, the Medication Administration Record (MAR) showed multiple instances where these parameters were not followed, resulting in incorrect administration of the medications. Despite in-service training for nurses, the Director of Nursing acknowledged that the issue persisted. Resident #242, with a diagnosis of Adrenocortical Insufficiency, was prescribed Levothyroxine for Hypothyroid. The resident reported receiving only one pill instead of the prescribed two, and photographic evidence supported this claim. Interviews with staff revealed discrepancies in medication administration, with one nurse admitting to discarding pills without verifying if they were taken. The MAR and blister pack counts confirmed that the resident did not receive the correct dosage on multiple occasions. Resident #66, who was prescribed methocarbamol for muscle spasms, did not receive the medication at the correct intervals. The Medication Administration Audit Report indicated that the medication was administered outside the scheduled 8-hour intervals on several occasions. Additionally, Resident #83, who was supposed to have a stool sample collected for C-Diff testing, did not have the sample collected as ordered. The Director of Nursing confirmed these deficiencies during an interview.
Failure to Schedule Timely Urology Appointment for Resident with Catheter
Penalty
Summary
The facility failed to ensure a timely urology appointment for a resident with a suprapubic urinary catheter. The resident was admitted with an indwelling urinary catheter, and a physician ordered a urology consult on March 4, 2025. However, the record showed no evidence of an upcoming or completed appointment. Observations on March 17 and 18, 2025, revealed very cloudy urine in the resident's catheter drainage tube, indicating a potential issue that required medical attention. Interviews with staff revealed a breakdown in the process for scheduling the urology appointment. Staff M, an RN, explained that the Medical Transportation Coordinator, Staff L, was responsible for making appointments but was unaware of any appointment for the resident. Staff L confirmed she had not made the appointment, citing a lack of information about the reason for the consult. Despite having the order, Staff L did not reach out to obtain the necessary details to proceed with scheduling, resulting in the failure to secure the required medical consultation for the resident.
Failure to Maintain Nutritional Status for Dialysis Resident
Penalty
Summary
The facility failed to maintain the nutritional status of a resident receiving dialysis therapy by not ensuring the ordered nutritional supplement was consumed. The resident, who was cognitively intact and dependent on activities of daily living, was at nutritional risk due to End Stage Renal Disease and a history of significant weight change. The care plan included providing supplements as ordered and having a Registered Dietician (RD) evaluate and make dietary recommendations. However, the resident reported not consuming the Nepro supplement at night due to stomach upset and expressed dissatisfaction with the facility's food, noting that no one had inquired about his food preferences. The RD was unaware that the resident was not consuming the ordered supplements and had not followed up on the resident's food preferences. The dietary progress note indicated the resident was at risk for malnutrition and underweight for age, with a need to encourage additional calories. Despite documentation in the Medication Administration Record of the resident consuming varying amounts of Nepro daily, the resident's refusal and the lack of follow-up on dietary preferences contributed to the deficiency in maintaining the resident's nutritional status.
Deficiencies in Oxygen Therapy Management
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents, leading to deficiencies in oxygen therapy management. For one resident with a respiratory disorder, the nebulizer mask was improperly stored on personal items without protective covering, contrary to the facility's protocol of storing it in a bag. Despite the Director of Nursing's awareness and the presence of a respiratory therapist, the nebulizer set was not replaced as required. Another resident used oxygen without a physician's order, which was only entered after surveyors noted the deficiency. The Director of Nursing confirmed that oxygen should be used per physician's orders, which was not adhered to in this case. Additionally, a third resident with COPD and other health issues was observed using oxygen at a higher rate than prescribed. The resident's care plan indicated a continuous oxygen flow of 3 liters per minute, but observations showed the concentrator set at 4.5 liters per minute. A nurse acknowledged the discrepancy but attributed it to the resident adjusting the machine, despite no documentation supporting this claim. These actions and inactions demonstrate a failure to follow physician orders and ensure proper respiratory care, as evidenced by the discrepancies in oxygen therapy management for the residents involved.
Inadequate Pain Management for a Resident
Penalty
Summary
The facility failed to ensure proper administration of pain medication for a resident, leading to inadequate pain management. Resident #109, who was admitted with a diagnosis including depression and an arterial stasis ulcer on the left lower leg, was prescribed tramadol for moderate to severe pain. The physician ordered 50 mg tramadol to be administered as two tablets orally every eight hours as needed. However, the resident reported instances where the medication was not provided as prescribed, including receiving only one tablet instead of two, which resulted in inadequate pain relief. On March 17, 2025, Resident #109 expressed concerns about the pain management, reporting a pain level of eight that could escalate to ten when seated in a wheelchair. The resident's left leg was wrapped in kerlix, and the left foot appeared swollen, indicating ongoing pain issues. A review of the medication monitoring control record confirmed that on March 19, 2025, the resident received only one tablet of tramadol instead of the prescribed two. The regional nurse consultant confirmed these findings, highlighting the facility's failure to administer pain medication as ordered.
Failure in Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure proper dialysis care and communication for a resident requiring hemodialysis. The resident, who was cognitively intact and dependent on activities of daily living, had a care plan indicating dialysis on Mondays, Wednesdays, and Fridays. However, the facility did not complete the required dialysis communication forms on several occasions, specifically on 03/03/25, 03/07/25, 03/10/25, 03/17/25, and 03/19/25. This lapse was confirmed by a Registered Nurse who stated that the forms were not kept in the designated narcotic book but in a binder at the nursing station. Additionally, the facility did not timely implement the Hemodialysis Dietitian's recommendations. The dietitian had advised discontinuing Tums and holding Cinacalcet based on lab values from 02/05/25. However, Tums was only discontinued 15 days later, and Cinacalcet was never held, as confirmed by the resident's Medication Administration Record. The Registered Dietitian acknowledged these discrepancies during an interview.
Failure to Individualize Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with PTSD was properly assessed and had an individualized care plan. The resident, who was cognitively intact and independent in activities of daily living, was admitted with a diagnosis of PTSD. The care plan for the resident, dated 03/18/24, addressed behaviors related to PTSD and Obsessive Compulsive Disorder but lacked specific details about the resident's trauma, behaviors, or triggers. During an interview, the resident confirmed the PTSD diagnosis, attributing it to an abusive childhood and adult experiences, and identified crowds as a trigger. The Social Service Director acknowledged that the care plan was generic and not tailored to the resident's personal experiences and triggers.
Staffing Shortages Lead to Delays in Medical Record Updates and Consults
Penalty
Summary
The facility failed to ensure sufficient staffing to manage the timely uploading of physician progress notes for a resident with diarrhea and to obtain a urology consult for another resident. Resident #83, who was cognitively intact and dependent on assistance for daily activities, had no physician progress notes uploaded for the year 2025. The medical records staff acknowledged the delay, citing increased census and high staff turnover as reasons for the backlog. The Director of Nursing recognized the need for additional training to assist with the uploading process, as a large stack of notes awaited processing. Resident #60, who had a suprapubic urinary catheter, did not have a timely urology consult appointment scheduled despite a physician's order. Observations revealed cloudy urine in the catheter's drainage tube, indicating a potential issue. The Medical Transportation Coordinator, responsible for scheduling appointments, had not made the appointment due to not receiving the necessary information and being overwhelmed with multiple responsibilities, including central supply duties. This lack of coordination and communication resulted in the failure to secure the necessary medical consultation for the resident.
Failure to Document Narcotic Removal in MARs
Penalty
Summary
The facility failed to ensure proper documentation of narcotic removal in the medication administration records (MARs) for three residents during a medication storage review. Resident #39 had discrepancies in the documentation of Tramadol removal, with missing entries for specific times on March 11 and March 12, 2025. Similarly, Resident #69's records showed missing documentation for Tramadol removal on March 17, 2025, at two different times. Additionally, Resident #71's records revealed missing documentation for Lorazepam removal on March 17 and March 18, 2025. These discrepancies were identified during a review of the medication binder on cart 1, where the medication control records were compared against the March 2025 MARs. The Director of Nursing (DON) was informed of these issues during an interview conducted on March 20, 2025. The lack of documentation for narcotic removal indicates a failure in maintaining accurate medication administration records, which is essential for ensuring the safe and effective management of residents' medications.
Failure to Monitor Psychotropic Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to ensure adequate monitoring of side effects and behaviors for psychotropic medications for a resident diagnosed with Generalized Anxiety, Major Depressive Disorder, Bipolar Disorder, Schizoaffective Disorder, and Diabetes Mellitus. The resident was prescribed multiple medications, including Venlafaxine, Quetiapine, and Divalproex Sodium, for their mental health conditions. However, upon review, it was found that there was no behavioral monitoring documented for the resident after their return from the hospital on two separate occasions. This lack of documentation was confirmed during interviews with facility staff, including an LPN and the Regional Nurse Consultant. The LPN interviewed was unaware of the behavioral monitoring procedures for the resident and could not find any documentation of such monitoring in the system. The Regional Nurse Consultant acknowledged that the resident should have had behavioral monitoring documented, especially since it was previously in place before the resident's hospitalizations. The oversight occurred because the resident was not put back on behavioral monitoring after returning from the hospital, leading to a deficiency in the facility's care practices.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The medication error rate at the facility was found to be 14.81 percent, significantly exceeding the acceptable threshold of 5 percent. During a medication pass observation, an LPN administered medications to a resident incorrectly. The resident was supposed to receive two eye drops in each eye, one docusate sodium tablet, and hydralazine only if the systolic blood pressure was greater than 160. However, the LPN administered only one eye drop in each eye, two docusate sodium tablets instead of one, and gave hydralazine despite the resident's systolic blood pressure being 156, which did not meet the criteria for administration. Additionally, the resident was supposed to receive two Senna 8.6 mg tablets, which were not administered because the LPN did not have them on the medication cart and had not retrieved them from central supply. The LPN acknowledged the errors upon review of the medication administration record and the physician's orders, admitting to the oversight in administering the incorrect dosages and failing to provide the necessary medication.
Medication Storage Deficiencies Observed
Penalty
Summary
The facility failed to ensure the proper storage of medications for two residents during a medication pass observation. For one resident, an LPN left a box of artificial tears unattended on top of a medication cart while she went into the resident's room to obtain his blood pressure. During this time, another resident was observed self-propelling down the hallway in front of the unattended medication cart, posing a risk of access to the unsecured medication. The LPN later acknowledged leaving the eye drops unsecured. In another instance, a resident with a diagnosis of Adrenocortical Insufficiency was observed with a pill cup containing medications left on his bedside table. The resident reported that a nurse had left the cup there after waking him up to take his thyroid medication, which was supposed to be taken before a meal. The resident noted that he was supposed to receive two Levothyroxine pills but was only given one, along with a Docusate Sodium capsule. The surveyor confirmed the presence of the medications in the pill cup on the bed tray, and photographic evidence was obtained.
Incomplete Medical Records and Undocumented Consults
Penalty
Summary
The facility failed to maintain complete and current medical records for several residents, as evidenced by missing physician progress notes and unscanned documentation. Resident #83's medical record was incomplete, with the last documented physician progress note dating back to November 2024, despite being admitted on an unspecified date. The medical records person admitted to not uploading any physician progress notes for the current year, acknowledging the incompleteness of Resident #83's records. Similarly, Residents #37, #60, #64, and #79 had missing or outdated physician visit documentation, with some records lacking any recent physician visits. The medical records person found unscanned physician visit notes for these residents, confirming that the records were not current. Additionally, the facility failed to document a dietitian consult for Resident #60, who was receiving nutrition and fluids via a feeding tube. The resident's current Minimum Data Set (MDS) assessment indicated the need for increased water flushes due to elevated blood urea nitrogen (BUN) levels, suggesting a potential need for more fluids. However, the Registered Dietitian (RD) did not document the consult or the decision not to increase fluids further, despite discussing it with a nurse practitioner. This lack of documentation contributed to the incomplete medical records for Resident #60.
Improper Installation of Fire Extinguishers
Penalty
Summary
The facility failed to maintain portable fire extinguishers in accordance with NFPA 101 standards. During a facility tour conducted on March 17, 2025, between 11:30 AM and 2:30 PM, it was observed that several fire extinguishers were improperly installed. Specifically, the fire extinguishers located by room 20, room 8, the main lobby, room 30, the Emerald Nurses Station, room 45, and room 25 were all found in cabinets with the top of the handle positioned above 60 inches from the floor. This placement does not comply with the required standards for accessibility and safety. The observations were made in the presence of the Maintenance Director, who confirmed the findings during the tour. These findings were subsequently reviewed with the administrator and the Maintenance Director during an exit conference held on the same day at 3:00 PM. The report does not mention any corrective actions or plans to address the deficiency, focusing solely on the improper installation of the fire extinguishers.
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. 1. The fire extinguishers noted in the fire extinguisher (FE) cabinets by room 20, by room 8, in the main lobby, by room 30, by the Emerald Nurses Station, by room 45, and by room 25 will be remounted to the required height. 2. Additional fire extinguisher locations will be reviewed for placement at the required height. 3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Portable Fire Extinguishers specific to maintaining fire extinguisher placement at the required height and will continue to monitor in accordance with NFPA standards. 4. Any findings will be reported to the monthly QAPI Committee for further review. 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. 1. The fire extinguishers noted in the fire extinguisher (FE) cabinets by room 20, by room 8, in the main lobby, by room 30, by the Emerald Nurses Station, by room 45, and by room 25 will be remounted to the required height. 2. Additional fire extinguisher locations will be reviewed for placement at the required height. 3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Portable Fire Extinguishers specific to maintaining fire extinguisher placement at the required height and will continue to monitor in accordance with NFPA standards. 4. Any findings will be reported to the monthly QAPI Committee for further review.
Corridor Door Closure Deficiency
Penalty
Summary
The facility failed to maintain their corridor doors in accordance with NFPA 101 standards. During a facility tour conducted on March 17, 2025, between 11:30 AM and 2:30 PM, it was observed that the patient room corridor door to room 47 would not completely close. This issue was caused by the bottom of the door rubbing against the floor, which prevented the door from closing properly. This deficiency was identified during observations made by the surveyors in the presence of the Maintenance Director. The findings were confirmed through an interview with the Maintenance Director, who was present during the observations. The issue was further discussed and reviewed at an exit conference with the administrator and the Maintenance Director on the same day at 3:00 PM. The deficiency was noted as a failure to comply with the requirements set forth in NFPA 101 (2012 and 2021 editions) and NFPA 80 (2010 and 2019 editions), which specify the standards for corridor doors to resist the passage of smoke and ensure proper closure.
Plan Of Correction
1. The resident room corridor door to room 47 was repaired to properly close. 2. Additional resident room corridor doors will be reviewed for proper closing. 3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Corridor- Doors specific to maintaining resident room corridor doors to properly close and will continue to monitor in accordance with NFPA standards. 4. Any findings will be reported to the monthly QAPI Committee for further review.
Medication Administration Deficiency in LTC Facility
Penalty
Summary
The facility failed to provide evidence that staff adhered to professional standards of quality care, specifically in medication administration, for 8 out of 12 residents reviewed. This deficiency was identified through clinical record reviews and interviews, revealing that staff did not follow physician orders for medication administration. The Director of Nursing acknowledged that after the evacuation of residents from another facility due to a storm, the Medication and Treatment Administration Records were initially taken by the departing staff. However, the records were later accessed and printed to ensure continuity of care. For Resident #8, the Medication Administration Record (MAR) showed multiple instances where medications were not signed as administered, despite the availability of the medications. This included several oral and intravenous medications prescribed for conditions such as BPH, depression, ALS, hypotension, and osteomyelitis. Similar issues were found for Resident #9, who had diagnoses including acute respiratory failure and a persistent vegetative state, with numerous missed doses of medications administered via G-tube and intravenously. Other residents, such as Residents #13, #11, #15, #12, #7, and #14, also experienced missed doses of critical medications for various conditions, including neuropathy, heart disease, diabetes, Parkinson's disease, and glaucoma. The MARs for these residents showed that nurses failed to document the administration of prescribed medications, indicating a systemic issue in medication management and documentation within the facility.
Failure to Provide Prescribed Care and Document Treatments
Penalty
Summary
The facility failed to provide necessary care and services consistent with the prescribed treatment plan for two residents. For one resident, the staff did not perform or document essential treatments such as tracheostomy care, skin integrity checks, wound dressing changes, and catheter care. This resident had complex medical needs, including a tracheostomy, a stage 4 pressure ulcer, and required total care for daily activities. The Treatment Administration Record showed multiple instances where nurses did not initial the completion of these treatments, indicating they were missed. Another resident, who also remained in the facility after a storm, did not receive proper skin checks, PICC line dressing changes, or arm circumference measurements as prescribed. This resident had diagnoses including Amyotrophic Lateral Sclerosis and a stage 4 pressure ulcer. The PICC line dressing was observed to be outdated, further indicating a lapse in care. The Director of Nursing acknowledged that the Medication and Treatment Administration Records were initially taken by another facility's staff, but she later accessed and printed them to ensure care continuity.
Failure to Provide Oral Hygiene Care
Penalty
Summary
The facility staff failed to provide necessary oral hygiene care for a resident who was unable to perform activities of daily living. The resident, who remained in the facility after a storm, had multiple diagnoses including seizures, persistent vegetative state, acute respiratory failure with hypoxia, a Stage 4 pressure ulcer in the sacral region, and essential hypertension. The resident required total care, had a tracheostomy, received tube feeding via a gastrostomy tube, used a wound vac for the sacral wound, and had a Foley catheter. During an observation, the resident was found lying in bed with a copious amount of dry yellowish-brown crusty substance inside her mouth and lips, indicating a lack of necessary mouth care. A registered nurse, who had just taken over the shift, was unaware of the care that had been provided to the resident.
Failure to Maintain PICC Line and Administer IV Medications
Penalty
Summary
The facility failed to ensure the proper care and maintenance of a PICC line for a resident, as evidenced by the staff's failure to change the PICC line dressing for multiple weeks. The facility's policy requires that a sterile dressing change using transparent dressings be performed at least weekly, or if the integrity of the dressing is compromised. An observation revealed that the resident's PICC line dressing was dated 20 days prior, indicating that the dressing had not been changed as required. Interviews with the Regional Consultant Nurse and the Director of Nursing confirmed that the dressing should be changed weekly, but the Treatment Administration Record (TAR) showed that the weekly PICC dressing change was not completed. Additionally, the staff failed to document the weekly monitoring of the PICC line by not placing their initials in the appropriate box. The resident involved had significant medical conditions, including Amyotrophic Lateral Sclerosis, a Stage 4 pressure ulcer, and Osteomyelitis, and was prescribed intravenous medications for treatment. The Medication Administration Record (MAR) indicated that the resident was prescribed DAPTomycin and Ertapenem Sodium Injection for infections, but the nurses failed to document the administration of these medications for several doses. The MAR also noted that the medication was unavailable on certain dates. This lack of documentation and failure to administer prescribed medications contributed to the deficiency identified by the surveyors.
Failure to Provide Timely Dialysis Leads to Resident Harm
Penalty
Summary
The facility failed to protect a newly admitted resident requiring dialysis treatments from neglect, resulting in serious harm and potentially contributing to the resident's death. The resident, who had multiple medical conditions including end-stage renal disease and was dependent on hemodialysis, did not receive dialysis for seven days after admission. This lapse in care led to the resident being transferred to a hospital emergency department with critically high serum potassium levels, a condition that can lead to severe cardiac issues. The deficiency was primarily due to a breakdown in communication between the facility and the dialysis provider. The facility's admissions personnel failed to ensure that the necessary documentation and communication were completed to arrange for the resident's dialysis. Despite having physician orders for dialysis, the resident was not taken for treatment because the dialysis provider did not receive the required information. Interviews with facility staff revealed a lack of awareness and understanding of the process for managing new admissions requiring dialysis, contributing to the oversight. The facility did not have a specific policy for dialysis services or a process for new admissions requiring such services, which further compounded the issue. Staff interviews indicated that there was confusion and a lack of communication regarding the resident's dialysis needs. The resident's condition deteriorated due to the absence of dialysis, leading to a hospital transfer where the resident was diagnosed with severe hyperkalemia and uremia. The resident passed away shortly after being admitted to the hospital.
Removal Plan
- The facility submitted appropriate reporting through the AHCA portal.
- Staff education was initiated for all nursing personnel, therapy staff, dietary staff, housekeeping/laundry staff, and administrative and department heads.
- A Quality Assurance and Performance Improvement (QAPI) meeting was held with the Executive Director, Medical Director, Director of Clinical Services, Plant Operations, Registered Dietician, MDS Coordinator, Business Development Director, Business Office Manager, Activities Director, and Admissions Director to review the data, root cause analysis, and plan for improvement.
- Staff interviews were conducted with the staff involved with the event.
- The facility installed a communication box outside the dialysis room as an additional way to communicate with the nurses in the dialysis unit.
- Nursing and Admission staff were educated on the improved communication process.
- The plan for improvement consisted of education/training for all staff providing care to residents and the Executive Director will complete a random audit of 10% of all residents to ensure no concerns related to abuse/neglect are identified.
- The findings will be reviewed by the QAPI committee until substantial compliance is identified.
- All newly hired staff will receive education in orientation regarding abuse/neglect.
- A full house audit was completed on all residents to determine any concerns for abuse/neglect.
- A certified letter was sent to those who did not attend advising that they could not work at the facility until the education was completed.
- The monthly QAPI meetings were held to discuss and review the corrective action plan.
- Education sign-in sheets were reviewed and verified with random staff interviews.
- All audits were reviewed and have been completed as stated.
- Random resident interviews were conducted and there were no allegations/complaints of abuse or neglect.
- The facility has changed dialysis companies to do in-house dialysis.
- The admission process has changed with the new company. Everything is done electronically through email from the admission personnel at the facility directly to admission personnel at the dialysis company.
- Electronic confirmations are obtained to verify the communication is complete.
- A paper communication is given to the executive director as well as placed in the communication box outside the dialysis door for the dialysis nursing staff.
- The facility CNA staff are now responsible for transporting their residents to and from dialysis to avoid any confusion as to where the residents are.
- All residents have assigned chair times for dialysis, which was reviewed and verified during the survey.
- Audits are being done weekly now and have been in 100% compliance.
- The nursing staff are aware of notifying the dialysis nurses if they have a resident that requires dialysis, and they are not on the list for that day.
- The External Business Development/Interim Admission Coordinator stated the process was to email admissions at the new dialysis company with all clinical info they need for admission. If she doesn't hear back, she reaches out to them again.
- A bright colored form and one goes to dialysis, and one goes to the executive director.
- The box outside the dialysis door is used for every resident so nurses are aware of a new patient.
Failure to Provide Timely Dialysis Services
Penalty
Summary
The facility failed to ensure that a newly admitted resident received timely dialysis services, resulting in the resident being transferred to a higher level of care. The resident, who had multiple medical conditions including chronic kidney disease, end-stage renal disease, and dependence on renal dialysis, was admitted to the facility with specific physician orders for hemodialysis. Despite these orders, the resident did not receive dialysis for seven days, leading to a critically high serum potassium level and other severe health issues. The deficiency was primarily due to a lack of communication and coordination between the facility and the dialysis provider. The facility's Director of Nursing (DON) and admissions personnel failed to ensure that the necessary documentation and communication were completed to arrange dialysis services for the resident. Interviews with staff revealed that there was confusion and a lack of awareness regarding the resident's dialysis needs, and the facility did not have a policy in place for managing new admissions requiring dialysis. As a result of these failures, the resident was sent to the emergency department with severe hyperkalemia and uremia, conditions that required immediate dialysis. The resident's condition was further complicated by sepsis and other infections, and the resident ultimately passed away in the hospital. The facility's lack of a structured process for handling dialysis admissions and ensuring timely communication with the dialysis provider contributed to the resident's deterioration and subsequent death.
Removal Plan
- The facility submitted appropriate reporting through the AHCA portal.
- Staff education was initiated for all nursing personnel, therapy staff, dietary staff, housekeeping/laundry staff, and administrative and department heads.
- A Quality Assurance and Performance Improvement (QAPI) meeting was held with the Executive Director, Medical Director, Director of Clinical Services, Plant Operations, Registered Dietician, MDS Coordinator, Business Development Director, Business Office Manager, Activities Director, and Admissions Director to review the data, root cause analysis, and plan for improvement.
- Staff interviews were conducted with the staff involved with the event.
- The facility installed a communication box outside the dialysis room as an additional way to communicate with the nurses in the dialysis unit.
- Nursing and Admission staff were educated on the improved communication process.
- The plan for improvement consisted of education/training for all staff providing care to residents and the Executive Director will complete a random audit of 10% of all residents twice weekly for 4 weeks, then weekly for 8 weeks to ensure no concerns related to abuse/neglect are identified.
- The findings will be reviewed monthly by the QAPI committee until substantial compliance is identified.
- All newly hired staff will receive education in orientation regarding abuse/neglect.
- A full house audit was completed on all residents to determine any concerns for abuse/neglect.
- A certified letter was sent to those who did not attend advising that they could not work at the facility until the education was completed.
- The monthly QAPI meetings were held to discuss and review the corrective action plan.
- Education sign-in sheets were reviewed and verified with random staff interviews.
- All audits were reviewed and have been completed as stated. There have been no further concerns regarding neglect for newly admitted dialysis residents or current dialysis residents receiving dialysis care.
- Random resident interviews were conducted over the course of the survey, and there were no allegations/complaints of abuse or neglect.
- The facility has changed dialysis companies to do in-house dialysis.
- The admission process has changed with the new company. Everything is done electronically through email from the admission personnel at the facility directly to admission personnel at the dialysis company.
- Electronic confirmations are obtained to verify the communication is complete.
- A paper communication is given to the executive director as well as placed in the communication box outside the dialysis door for the dialysis nursing staff.
- The facility CNA staff are now responsible for transporting their residents to and from dialysis to avoid any confusion as to where the residents are.
- All residents have assigned chair times for dialysis, which was reviewed and verified during the survey.
- Audits are being done weekly now and have been in 100% compliance.
- The nursing staff are aware of notifying the dialysis nurses if they have a resident that requires dialysis, and they are not on the list for that day.
- The process was to email admissions at the new dialysis company with all clinical info they need for admission. If she doesn't hear back by the following morning, she reaches out to them again.
- A bright colored form and one goes to dialysis, and one goes to the executive director.
- The box outside the dialysis door is used for every resident so nurses are aware of a new patient.
Failure to Provide Timely Dialysis Services
Penalty
Summary
The facility failed to ensure that a newly admitted resident, who was dependent on dialysis, received timely dialysis services. The resident, who had multiple complex medical conditions including end-stage renal disease, was admitted with a physician's order for hemodialysis three times a week. Despite this, the resident did not receive dialysis for seven days, leading to an emergency transfer to a higher level of care. The deficiency arose from a breakdown in communication and procedural lapses within the facility. The admissions personnel claimed to have sent the necessary information to the dialysis provider, but the dialysis provider did not receive it until the resident's condition became critical. Interviews with various staff members revealed a lack of awareness and understanding of the process for managing new admissions requiring dialysis, contributing to the oversight. As a result of the facility's failure to communicate and coordinate dialysis services, the resident developed severe hyperkalemia and uremia, necessitating emergency medical intervention. The resident was diagnosed with additional complications, including sepsis and a large stage 3 pressure injury, and ultimately passed away shortly after being transferred to the hospital.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of two residents regarding portion sizes, following a change in ownership. Resident #1 expressed dissatisfaction with the smaller portion sizes provided after the new company took over, stating that the portions were insufficient for his needs. Despite his repeated requests for larger portions, the facility maintained that they could only provide larger or double portions when deemed medically necessary. The Certified Dietary Manager (CDM) confirmed this policy change and stated that the resident's previous preference for larger portions was no longer honored. Similarly, Resident #4 reported that he no longer received his preferred large portions after the change in ownership. The facility's policy now requires a medical reason for providing larger portions, as confirmed by the CDM and the Dietitian. The Dietitian, who was new to the facility, explained that a nutritional assessment must be completed to determine if a resident meets the criteria for medically necessary larger portions. This policy shift has resulted in the facility not accommodating the residents' preferences for larger portion sizes unless there is a documented medical need.
Expired Milk Served to Resident
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by serving and storing milk beyond the manufacturer's expiration date. This deficiency was identified during an observation of the kitchen refrigerator, where a red crate containing over 30 individual chocolate milk cartons with expired dates was found. Additionally, two cartons of expired chocolate milk were noted on a tray with lunch items. The Certified Dietary Manager confirmed that the milk was out of date and acknowledged that the milk was delivered in this condition, indicating a failure to check expiration dates upon delivery and before serving to residents. Resident #5, who has a preference for chocolate milk, reported being served expired milk on multiple occasions and provided photographic evidence of the expired milk cartons and corresponding tray tickets. The issue of expired milk was previously raised during a Resident Council meeting, yet the facility did not develop a plan to prevent recurrence. The Resident Council President was unaware that the problem persisted, despite previous efforts to address it by obtaining fresh milk from the supplier.
Elopement Incident Due to Inadequate Supervision and Malfunctioning Wanderguard System
Penalty
Summary
The facility failed to provide adequate supervision and functioning wanderguard doors for a resident identified as at risk for elopement. Resident #1, admitted with severe cognitive impairment and a BIMS score of 0, was care planned for elopement risk with an electronic monitoring device in place. Despite this, Resident #1 exited the facility undetected, walking 1.4 miles away and being found by the police displaying confusion. The facility's Policies and Procedures required daily checks of the wander monitoring system device, but the resident was able to leave without staff knowledge. An investigation revealed that Resident #1 likely exited through unlocked/disalarmed emergency exit doors in a unit under construction. The facility lacked security cameras covering these doors, hindering the ability to track the resident's movements. Staff interviews indicated gaps in monitoring and response, with the primary nurse unaware of the resident's whereabouts upon starting their shift. The Assistant Maintenance Director confirmed issues with the wanderguard sensors, as the door could be opened without alarming when tested by surveyors and facility staff. The deficiency resulted in Immediate Jeopardy, with the resident exposed to hazards such as a 4-lane road with high-speed limits during their unsupervised walk. The facility's failure to prevent elopement for a resident at high risk highlights systemic issues in supervision, monitoring, and door security. Despite the resident's known elopement risk and the presence of monitoring devices, lapses in staff awareness, door functionality, and surveillance contributed to the incident, posing serious risks to the resident's safety and well-being.
Failure to Accurately Assess Resident for Wandering
Penalty
Summary
The facility failed to accurately assess a resident for wandering behaviors. Resident #1, who was admitted to the facility on an unspecified date, exhibited exit-seeking and wandering behaviors, leading to a room change on 03/18/24. The resident was care planned for elopement risk on 03/19/24, with an intervention of an electronic monitoring device placed on the right ankle. However, a comprehensive assessment dated an unspecified date documented that the resident had severe cognitive impairment and did not exhibit any wandering behaviors, indicating a discrepancy in the resident's assessment.
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Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
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