Aviata At Santa Barbara
Inspection history, citations, penalties and survey trends for this long-term care facility in Cape Coral, Florida.
- Location
- 216 Santa Barbara Blvd, Cape Coral, Florida 33991
- CMS Provider Number
- 105588
- Inspections on file
- 26
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 35 (8 serious)
Citation history
Health deficiencies cited at Aviata At Santa Barbara during CMS and state inspections, most recent first.
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.
A resident with cognitive and mental health diagnoses, who had previously expressed a desire to remain in LTC, exhibited an episode of aggressive behavior that led to an involuntary emergency mental health examination and transfer to a hospital. The facility’s documentation shows the DON and provider described the behavior as dangerous and initiated the transfer, but the clinical record lacked evidence that a bed-hold policy was offered at the time of transfer. Hospital records indicated the resident was calm, oriented, medically cleared, and did not meet criteria for continued involuntary psychiatric placement, and he was deemed ready for discharge. When the hospital sought to return the resident, the DON, Administrator, and Admissions Director reported that facility leadership and regional management decided not to accept him back or to any sister facilities, without documented basis for discharge, resulting in his placement at another nursing home approximately 73 miles from his family.
A resident with multiple chronic conditions and documented full code status was found unresponsive without pulse or respirations by a CNA, who notified the RN. The RN assessed the resident, did not verify code status, believed the resident was on hospice, and either initially instructed staff to clean and cover the body or, per her later account, called a code blue and performed CPR with an LPN for about 20 minutes before stopping. EMS was not called at that time, and the RN acknowledged she discontinued CPR and did not activate 911 despite the facility policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival. Hours later, after the DON inquired whether 911 had been called, the RN contacted EMS and briefly reinitiated CPR shortly before EMS arrived and documented rigor mortis, algor mortis, and absence of vital signs, with resuscitation deemed futile. Surveyors found that staff failed to follow the CPR policy, did not check the resident’s code status, and improperly stopped CPR and delayed EMS activation, resulting in an Immediate Jeopardy deficiency under F726.
A resident with full code status was found in cardiac and respiratory arrest, and an RN and an LPN initiated CPR but did not activate EMS as required by policy. After about 20 minutes, the RN unilaterally stopped CPR, effectively pronounced death without authority, and did not verify the resident’s code status, later stating she believed the resident was on hospice. EMS was not called until approximately four hours later, when CPR was briefly restarted and a CNA was directed to perform chest compressions. The investigation found that the RN had no documented orientation or skills competency assessment, her BLS/CPR training was fully online without hands-on instruction, and both the LPN’s and CNA’s BLS/CPR certifications were expired, demonstrating a broader failure to ensure staff CPR competency and proper emergency response.
A resident with psychiatric and behavioral diagnoses, intact cognition on MDS, and a care plan goal to remain in LTC exhibited escalating aggressive behavior, including yelling at others and damaging room walls and doors, leading a provider to order an involuntary emergency examination and transfer to the hospital. The facility’s policy required that residents sent emergently to acute care be permitted to return unless specific regulatory discharge criteria were met and documented, and that required transfer/discharge procedures be followed. However, the DON confirmed there was no documentation that a bed hold was offered, the Administrator acknowledged there was no documentation of the basis for discharge, and the Admissions Director reported that regional leadership directed staff not to accept the resident back or at any sister facilities. As a result, the resident was not allowed to return after hospitalization and was instead placed at a distant facility, and later went home with the emergency contact, who reported significant distress and difficulty managing the resident’s care.
A resident with a history of traumatic brain injury, mood and anxiety disorders, and intact cognition on recent MDS had a care plan goal to remain in LTC at the facility. After an acute behavioral episode involving yelling and property damage, the resident was Baker Acted and transferred to the hospital. The facility’s policy required that residents sent emergently to acute care be permitted to return unless specific discharge criteria were met, and that a bed-hold policy be offered; however, there was no documentation that a bed hold was offered or that regulatory criteria for facility-initiated discharge were met. Hospital records showed the resident was calm, cooperative, and did not meet criteria for involuntary psychiatric placement, but the facility, following regional direction, refused to readmit the resident, leading to placement in another nursing home far from the resident’s family.
A resident with chronic incontinence and intact decision-making abilities was found by a family representative lying in urine-soaked bedding without an incontinent brief or pad and with a strong urine odor. Review of CNA records for two months showed multiple day, evening, and night shifts with no documented incontinent care, and some entries marked as not applicable. A CNA reported that residents are toileted every 2 hours and on request, but the DON and regional nurse consultant confirmed there was no documentation that this resident received the necessary incontinence care.
Two residents with intact cognition reported that a CNA verbally abused and roughly handled one of them during incontinence care, yelling, making demeaning comments about the resident’s weight and mobility, and turning the resident so abruptly that she had to catch herself to avoid falling. The roommate stated the CNA was loud, mean, and threatening, causing her to become fearful and hide under her blanket. An LPN confirmed the CNA loudly complained about the resident within hearing distance, and another resident reported that the same CNA routinely entered his room at night, slammed on lights without explanation, yelled at him and his roommate, and talked down to them, leading to the CNA being kept out of his room. These actions demonstrated a failure to protect residents from verbal and mental abuse.
Facility staff did not follow established processes to ensure laboratory tests were completed as ordered for three residents. For one resident, blood work ordered to monitor edema and shortness of breath was not obtained despite documentation indicating otherwise. Another resident's Hemoglobin A1C was not collected as ordered, and a third resident's labs were not drawn as scheduled. The DON confirmed that required procedures for tracking and documenting lab orders were not followed, resulting in multiple missed laboratory tests.
Two residents with a history of falls and major injuries did not receive appropriate fall prevention interventions as outlined in their care plans. One resident, with conditions like Metabolic Encephalopathy, was not provided with hipsters or Dysem, leading to a fall and fracture. Another resident, with Hemiplegia, lacked floor mats by the bed, resulting in a fall and femur fracture. Staff were unaware of these interventions, and there was no documentation verifying their implementation.
Two residents with severe cognitive impairment and mobility issues did not receive appropriate interventions as per their care plans, leading to injuries. One resident was not wearing hipsters, resulting in a fall and fracture, while another lacked required floor mats, leading to a fall and subsequent fracture. Staff were unaware of these care plan requirements, and there was no documentation verifying daily completion of interventions.
A resident with dementia was found with bruising and an acute femoral fracture, but the facility failed to report the injury of unknown source and serious bodily injury to the State Survey Agency within the required timeframe. Despite immediate assessment and notifications by an LPN, the report was delayed by 48 hours, leading to a deficiency finding.
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
Failure to Permit Resident’s Return and Inadequate Discharge/Bed-Hold Process After Psychiatric Evaluation
Penalty
Summary
The deficiency involves the facility’s failure to allow a resident to return following a hospitalization and involuntary mental health evaluation, and failure to follow required transfer, discharge, and bed-hold procedures. The resident had been admitted with diagnoses including problems with social environment, mild cognitive impairment due to unknown origin, a condition with mixed features, and an adjustment disorder with mixed anxiety and depressed mood. A quarterly MDS showed intact cognition and no physical or verbal behavioral symptoms directed toward others at that time. The resident’s care plan documented that he wished to remain in LTC at the facility and identified goals related to managing verbally aggressive behaviors such as yelling at other residents. Progress notes show that on one day the provider documented that the resident had been increasingly agitated, responding to internal stimuli, refusing medications and care, and exhibiting aggressive and impulsive behavior that was considered dangerous to himself. The provider stated that the resident had failed all staff interventions to keep him safe and required a higher level of care, leading to an involuntary emergency mental health examination. The DON documented in a late entry that the resident had a burst of anger with uncontrolled behavior, including screaming, kicking the entrance door of his room and creating a hole in the wall, and kicking another wall near his TV, also creating a large hole. Law enforcement and EMS were notified, a Baker Act order was presented, and the resident was transported from the facility under this order. The DON noted that the behavior was frightening to staff and other alert residents and that the resident needed to be out of the facility for the safety of staff and residents. The clinical record did not contain documentation that a bed-hold policy was offered to the resident or his representative at the time of transfer. The hospital record shows that the resident was admitted under involuntary commitment for evaluation of mental health concerns following reported aggression at his memory care facility. On admission to the hospital, he was calm, cooperative, and oriented, with no acute distress, and denied suicidal or homicidal ideation. He was medically cleared in the ED, and a psychiatric evaluation, including telemedicine consultation, determined that he did not meet criteria for involuntary inpatient or outpatient psychiatric placement; the Baker Act and associated safety protocols were discontinued, and he was cleared for discharge from a psychiatric standpoint. Case management and social work became involved because the prior SNF refused to accept him back, and alternative placement options were explored. The DON confirmed there was no documentation that a bed hold was offered and stated that the resident’s emergency contact had declined the bed hold, and that when the resident was ready for discharge from the hospital, the facility refused to take him back because she believed he would be better off in a group home due to his age and volatile behavior. The emergency contact reported that, because the facility refused readmission, the resident was placed in another nursing home approximately 73 miles away, and she expressed a desire for him to return to the original facility. The Admissions Director stated that several days after the transfer, the hospital notified the facility that the resident was ready to return, but her regional leader instructed her not to accept the resident and not to admit him to any sister facilities. The Administrator acknowledged that a bed hold was not offered and that there was no documentation of the basis for the resident’s discharge, and stated that the regional team decided not to allow the resident to return based on information from facility staff.
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 identified resident's #2 discharge documentation was reviewed. Resident no longer resides in facility. 2. A 100% audit of all transfers/discharge forms and bed hold within the past 30 days was conducted to verify compliance with F627 requirements. Any discrepancies identified were immediately corrected, including issuance of proper notices and documentation updates. Residents under consideration for transfer/discharge will be reviewed to ensure full compliance with regulatory requirements. 3. A discharge checklist was developed to ensure all required steps are completed prior to any transfer or discharges. Education completed with all licensed nurses on discharge checklist and transfer/discharge forms and bed hold education. All planned discharges will be reviewed by IDT prior to discharge to ensure compliance. 4. Social Services Director or designee will conduct 4x/week audits of all transfers/discharges for 4 weeks, then, 3x/week x 4 weeks; then, 2x/week x 4 weeks; then, weekly x 4 weeks to ensure regulatory compliance. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 or until committee determines substantial compliance has been met.
Failure to Provide Timely 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 and activation of EMS, to a resident with a documented full code status. The resident had diagnoses including peripheral vascular disease, COPD, vascular dementia, and Alzheimer’s disease, and had a physician’s order and care plan indicating full code status. In the early morning hours, a CNA found the resident unresponsive in bed and notified the RN on duty. Assessments documented by the RN indicated absence of pulse and respirations and nonreactive pupils. Despite this, EMS was not called at that time, and the RN later stated she believed the resident was on hospice and did not verify the code status as required by facility policy. According to witness statements, the RN initially instructed a CNA to clean and cover the resident, indicating she believed the resident had died. In a separate statement, the RN reported that she called a code blue, and she and an LPN brought the crash cart and performed CPR for approximately 20 minutes. The LPN corroborated that CPR was performed and that the RN stopped CPR after about 20 minutes, stating that the resident was gone or words to that effect. The RN acknowledged that she did not call 911 and discontinued CPR despite the resident’s full code status and the facility policy requiring immediate initiation of CPR and continuation until EMS arrival or resident response. The DON received a text message from the RN around 2:42 a.m. that the resident had expired, but EMS was not contacted until hours later. The RN reported that at approximately 5:50 a.m., the DON called the facility and asked if 911 had been called; only then did the RN contact EMS and reinitiate CPR roughly four hours after the resident was first found without pulse or respirations. EMS records show activation shortly after this call, arrival to find staff performing CPR, and documentation of rigor mortis, algor mortis, and lack of respirations and pulse, with resuscitation deemed futile. The facility’s investigation and the Medical Director’s interview confirmed that the resident was a full code and that staff did not follow the established policy to verify code status, immediately call 911, and continue CPR until EMS arrival, leading to the determination of Immediate Jeopardy. The facility’s policy titled “Florida Cardiopulmonary Resuscitation (CPR)” required that CPR be provided to all residents in cardiac arrest unless a fully executed Florida DNRO was present, and that in the event of cardiac arrest, staff must immediately call for assistance, overhead page a code blue, and begin CPR in the absence of a DNRO. The policy further required that CPR continue until EMTs assume responsibility or the resident responds. In this incident, the RN did not confirm the resident’s code status, did not immediately activate EMS, and discontinued CPR without appropriate authority, while the LPN followed the RN’s direction. The facility’s root cause analysis identified that the nurse believed the resident was hospice, did not check the code status, and did not follow policy regarding when CPR can be discontinued and when 911 must be called. Surveyors determined that this failure to immediately activate EMS and maintain CPR for a full code resident until EMS arrival constituted a failure to provide appropriate lifesaving interventions in the event of cardiac and/or respiratory arrest. This placed other residents with full code status at a likelihood of serious injury or death from not receiving appropriate basic life support. The deficiency was cited under F726 and initially determined to be Immediate Jeopardy before being reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Failure to Ensure Competent CPR Response and EMS Activation for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that clinical staff had the competencies to respond appropriately to a cardiac and respiratory arrest for a resident with full code status. A resident designated as full code was found without a pulse or respirations at approximately 2:07 a.m. The RN on duty (RN Staff A) and an LPN (LPN Staff B) initiated CPR but did not activate EMS as required by facility policy, which states that CPR must be initiated immediately in the absence of a valid DNR and continued until Emergency Medical Technicians assume responsibility or the resident responds. After about 20 minutes of CPR, RN Staff A stopped resuscitation efforts, stated that the resident was dead based on lack of vitals and respirations, and effectively pronounced the resident’s death despite having no authority to do so and without contacting EMS. The report notes that RN Staff A believed the resident was on hospice and did not check the resident’s code status before deciding not to call 911. LPN Staff B reported that he assumed RN Staff A had called 911 and continued chest compressions for about 20 minutes until RN Staff A “called the code” and left, stating they were not going to bring the resident back. LPN Staff B acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours later, around 6:00 a.m., after the DON called the facility and instructed RN Staff A to contact EMS, CPR was restarted and EMS was activated. A CNA (CNA Staff D) was then instructed by RN Staff A to place a board under the resident and perform chest compressions; the CNA performed approximately 5–6 compressions until EMS arrived and directed her to stop. EMS subsequently pronounced the resident’s death. The investigation also identified multiple competency and credentialing issues related to emergency response and CPR. RN Staff A’s personnel file lacked documentation of any orientation or skills competency assessment despite her hire and later promotion to weekend supervisor. Her BLS/CPR certification was obtained through a fully online course without an instructor-led, hands-on component or live feedback, contrary to accepted national standards. LPN Staff B’s BLS/CPR certification was expired, and the CNA’s BLS/CPR certification was also expired, even though facility policy stated CNAs were not allowed to perform CPR, including chest compressions. The facility’s own documents indicated that skills competency assessments were required upon hire and annually, but no such assessment was found for RN Staff A. Leadership interviews confirmed that newly employed licensed nurses were expected to receive clinical orientation and complete skills competencies before working independently, and that RN Staff A had not completed these processes. These actions and omissions led to the determination that staff were not adequately trained or competent to respond to cardiac and respiratory arrests, resulting in Immediate Jeopardy.
Failure to Readmit Hospitalized Resident and Omission of Required Bed-Hold/Discharge Procedures
Penalty
Summary
The deficiency involves the facility’s failure to comply with federal and state transfer and discharge requirements by not permitting a resident to return following an emergency hospital transfer and by not following its own policies and procedures. The facility’s written policy, “Transfer/Discharge Notification & Right to Appeal,” states that residents sent emergently to an acute care setting must be permitted to return to the center, and that if the center initiates a discharge while the resident is in the hospital, it must show evidence that the resident’s status at the time of return meets specific regulatory criteria. The policy also incorporates federal and Florida requirements that govern when a transfer or discharge may be initiated by the facility. The resident at issue had been admitted with multiple psychiatric and behavioral diagnoses, including a problem with social environment, history of [R], mild [R] of unknown origin, [R] due to known [R], condition with mixed features, [R], and adjustment with mixed [R] and depressed [R]. A quarterly MDS showed intact cognition with a BIMS score of 15 and no physical or verbal behavioral symptoms directed toward others, and the resident’s care plan documented a wish to remain in LTC at the facility. The care plan also identified behaviors of verbal aggression, including yelling at other residents and telling them to “Shut your [R].” Progress notes show that on [R], a [R] provider documented that the resident had been [R], responding to internal stimuli, presenting with bizarre and tangential behavior, refusing all medications and staff care, and being aggressive and impulsive to the point of being considered a danger to self. The provider stated that the resident had failed all staff interventions to keep him safe and required a higher level of care, and ordered an involuntary emergency examination ([R]). The DON later documented in a late entry that the resident had a burst of anger with uncontrolled behavior, including screaming, kicking the entrance door of his room, creating holes in the wall, and damaging the area near his TV. Following this episode, the resident was transferred emergently to the hospital. The DON verified that there was no documentation that a bed hold was offered to the resident at the time of transfer, although she stated that the resident’s emergency contact declined the bed hold. The DON also confirmed that when the hospital later notified the facility that the resident was ready for discharge, the facility refused to accept the resident back, and she stated she thought the resident would be better off in a group home due to his age and volatile behavior. The Admissions Director reported that 4–5 days after the transfer, the hospital notified the facility that the resident was ready to return, but her regional leader instructed her not to accept the resident and not to accept him at any sister facilities. The Administrator confirmed that a bed hold was not offered and that there was no documentation of the basis for discharge of the resident. Because the facility refused readmission, the resident’s emergency contact reported that the resident was placed in another nursing home approximately 73 miles away, and that he later called her in the middle of the night screaming for help, leading her to take him home. She reported that this caused her distress, missed work, and emotional problems because she did not know how to manage his care, and that the resident was not doing well at home. The surveyors concluded that the facility failed to allow the resident to return post-hospitalization and did not follow required transfer/discharge procedures and documentation requirements.
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 identified resident's #2 discharge documentation was reviewed. Resident no longer resides in facility. 2. A 100% audit of all transfers/discharge forms and bed hold within the past 30 days was conducted to verify compliance with F627 requirements. Any discrepancies identified were immediately corrected, including issuance of proper notices and documentation updates. Residents under consideration for transfer/discharge will be reviewed to ensure full compliance with regulatory requirements. 3. A discharge checklist was developed to ensure all required steps are completed prior to any transfer or discharges. Education completed with all licensed nurses on discharge checklist and transfer/discharge forms and bed hold education. All planned discharges will be reviewed by IDT prior to discharge to ensure compliance. 4. Social Services Director or designee will conduct 4x/week audits of all transfers/discharges for 4 weeks, then 3x/week x 4 weeks; then, 2x/week x 4 weeks; then, weekly x 4 weeks to ensure regulatory compliance. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 or until committee determines substantial compliance has been met.
Failure to Permit Resident’s Return and Offer Bed Hold After Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to allow a resident to return following a hospital transfer and to follow its own transfer/discharge and bed-hold policies. The facility’s policy stated that residents sent emergently to an acute care setting must be permitted to return, and that if the center initiates a discharge while the resident is in the hospital, it must show evidence that the resident’s status at the time of return meets specific regulatory criteria. The resident, admitted with diagnoses including chronic Hepatitis C, traumatic brain injury history, mild cognitive impairment, mood and anxiety disorders, and adjustment disorder, had a care plan goal to remain in LTC at the facility. Prior assessments, including a quarterly MDS, showed intact cognition and no documented physical or verbal behavioral symptoms directed toward others at that time. On the day of transfer, facility documentation described an acute behavioral episode in which the resident was reported as manic, psychotic, delusional, refusing medications and care, and considered a danger to self and others. The DON documented that the resident had a burst of anger, screamed, kicked the entrance door and walls creating holes, and disrupted his room for approximately 30 minutes, leading to notification of law enforcement and EMS and a Baker Act (involuntary emergency examination) order from the psychiatric provider. The DON noted that the behavior was frightening to staff and other alert residents and that the resident needed to be out of the facility for safety. The resident was transported to the hospital under this involuntary status. Hospital records showed that upon admission the resident was calm, cooperative, oriented, and without acute psychiatric distress, and that he did not meet criteria for involuntary inpatient or outpatient psychiatric placement. The Baker Act orders were discontinued, and he was cleared for discharge with outpatient recommendations. Case management and social work became involved because the prior facility refused to accept him back. The facility’s clinical record lacked documentation that a bed-hold policy was offered at the time of transfer, and the DON later acknowledged there was no documentation of a bed hold offer or of the basis for discharge, stating that the emergency contact declined the bed hold and that the regional team decided not to allow the resident to return or be admitted to sister facilities. As a result, the resident was discharged to another nursing home approximately 73 miles away from his family, and his emergency contact reported distress related to his placement and subsequent fall at the new facility.
Failure to Document and Provide Necessary Incontinent Care
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to provide and document incontinent care for a resident who was always incontinent of bowel and bladder. The resident, admitted with diagnoses including chronic obstructive pulmonary disease, traumatic brain injury, anxiety, and major depressive disorder, had an MDS dated 1/16/26 indicating intact cognitive skills for daily decision making and complete incontinence of bowel and bladder. The resident’s family representative reported arriving on 2/4/26 to find the resident in bed with bedding soaked with urine, no incontinent brief or pad in place, and a strong urine odor. This account suggested that necessary incontinence products were not in use at that time. Review of CNA documentation for January and February 2026 showed multiple shifts with no recorded incontinent care for this resident. In January, there was no documentation of incontinent care on multiple specified dates across day, evening, and night shifts, and some entries were marked “N/A.” In February, there was no documentation of incontinent care on several consecutive days on both day and evening shifts. A CNA stated that residents are toileted every two hours and when they request it, but the Director of Nursing and Regional Nurse Consultant confirmed the lack of documentation that this resident received necessary incontinence care.
Failure to Prevent Verbal and Mental Abuse by CNA
Penalty
Summary
The facility failed to protect residents from verbal and mental abuse by a CNA, resulting in substantiated abuse of two cognitively intact residents. One resident with Parkinson’s disease, which caused slow and deliberate movements, reported that around Christmas a CNA changed her brief after an incontinence episode while yelling at her, ignoring her request to slow down, and roughly turning her by grabbing the sheet and whipping her to the side, causing the resident to catch herself on the windowsill to avoid falling. The resident reported that the CNA called her “heavy,” stated “I don’t get paid enough to do this. My back hurts,” complained that the resident could not get into her wheelchair, and “bitched at me for not being able to get into my wheelchair.” The resident also reported that the CNA rolled her roughly onto her right side using the pad and that she overheard the CNA yelling to the night nurse about her. The resident later told a psychiatric provider she felt emotional discomfort following this interaction and that the CNA’s rough handling and failure to listen made her feel inconsequential. A roommate with intact cognition corroborated that the CNA was very loud and mean, yelled at the first resident during the brief change, and told her she could break her back changing her. This roommate stated she became nervous and scared, hid under her blanket, and did not speak up out of fear of what the CNA might do to her. An LPN reported that when the first resident activated her call light, the CNA, who “likes to talk loudly,” said out loud words to the effect of “what she wants now,” and vented loudly enough outside the closed door that the resident could hear, prompting the resident to call the nurses’ station and complain that if the CNA had time to talk, she had time to provide care. Another resident reported that the same CNA would enter his room in the middle of the night, slam on the lights without explanation, insist that care be done her way, yell at him and his cognitively impaired roommate, and talk down to them, leading to the CNA eventually being restricted from his room. The administrator later confirmed that, based on collected statements from the involved residents, the allegation of abuse was substantiated.
Failure to Complete and Track Ordered Laboratory Tests
Penalty
Summary
Facility staff failed to ensure that laboratory tests were completed as ordered for three residents. For one resident, an APRN ordered a complete metabolic panel (CMP), complete blood count (CBC), and Pro-BNP to monitor persistent bilateral leg edema and shortness of breath. Although the Treatment Administration Record indicated that blood was drawn, there were no results in the clinical record, and the Director of Nursing (DON) and Regional Nurse confirmed the labs were never obtained. Another resident had a practitioner's order for blood work, including a Hemoglobin A1C, but only part of the blood work was collected, and the Hemoglobin A1C was missed. A third resident had a lab order that was not drawn as scheduled, requiring the labs to be reordered and rescheduled. The facility's process required practitioners and licensed nurses to print laboratory requisitions and place them in a binder for the laboratory technician, who would then collect specimens and document them in a laboratory log. The DON stated that Unit Managers were responsible for ensuring labs were completed and results reported to the physician, using daily reports and morning meetings to track orders. However, these processes were not followed, resulting in missed and untracked laboratory tests for the affected residents. An audit revealed additional residents with missing labs during the same period.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to provide appropriate interventions to prevent falls for two residents with a history of falls and major injuries. Resident #1, who was admitted with diagnoses including Metabolic Encephalopathy and Osteoarthritis, was identified as being at risk for recurrent falls due to various factors such as gait/balance problems and impaired cognition. Despite the care plan indicating the use of hipsters and Dysem to prevent falls, staff did not ensure these interventions were in place, leading to an unwitnessed fall and subsequent fracture requiring surgical repair. Resident #2, admitted with conditions such as Moderate Protein Malnutrition and Hemiplegia, was also at risk for falls. The care plan included the use of floor mats on both sides of the bed to prevent falls. However, observations revealed that these mats were not in place, and staff were unaware of the requirement, resulting in a fall that led to a fracture of the right femur. Interviews with staff and the Director of Nursing (DON) highlighted a lack of awareness and documentation regarding the fall prevention interventions outlined in the care plans. The DON confirmed that the interventions were listed on the care plans and CNA Kardex, but there was no documentation verifying their implementation, contributing to the deficiencies observed.
Plan Of Correction
F789: Free of Accident Hazards/Supervision/Devices (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #1, Dycem was placed in resident wheelchair on Care plan and Kardex updated. Resident #1, Hipsters were put on resident, on Care plan and Kardex updated. Resident #2, floor mats were placed on each side of the bed. Educated CNAB on resident #1 on interventions. Educated CNAC on resident #2 on intervention. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: A Quality review that contains look period of 60 days was completed to ensure residents with that the care plans, kardex and interventions are in place. Issues or concerns were addressed as they were identified. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Director of Clinical Services/Designee re-educated the licensed nurses and certified nursing assistants on the components of this regulation with an emphasis on: management policy and procedure, care plan and kardex to be updated with interventions, intervention to be in place. During clinical morning meeting, Director of Nursing/Designee will review resident to ensure care plan, kardex and intervention in place. Newly hired licensed nurses and certified nursing assistants will receive education in orientation. (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: The facility Director of Clinical Services/designee will conduct a weekly audit of 5 residents to ensure interventions are care planned, kardex updated and intervention in place weekly x 4 weeks, and then every 2 weeks x 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met and recommends moving to quarterly monitoring by the Divisional Director of Clinical Services when completing their systems review.
Failure to Implement Care Plan Interventions for Residents
Penalty
Summary
The facility failed to provide appropriate interventions for two residents with a history of major injuries. Resident #1, who had severe cognitive impairment and required assistance with transfers, was not wearing hipsters as per the care plan, which were intended to prevent injuries. The resident had a history of gait and balance problems, poor communication, and hearing issues. Despite these risks, staff did not ensure the resident was wearing the hipsters, and the resident sustained an unwitnessed fall resulting in a fracture that required surgical repair. Resident #2, also with severe cognitive impairment and decreased physical mobility, was at risk for falls and related injuries. The care plan required floor mats to be placed on both sides of the bed to prevent falls. However, during observations, no floor mats were found in the resident's room, and staff were unaware of the requirement. The resident had previously been found on the floor beside the bed, and later sustained a fracture requiring hospital treatment. The deficiencies were identified through observations, interviews, and record reviews, revealing that staff were not following the care plans for these residents. The Director of Nursing was unaware of the specific interventions required for these residents, and there was no documentation verifying that the interventions were being completed daily. This lack of adherence to care plans and communication among staff contributed to the residents' injuries.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #1, Dycem was placed in resident wheelchair on Care plan and Kardex updated. Resident #1, Hipsters were put on resident, on Care plan and Kardex updated. Resident #2, floor mats were placed on each side of the bed on Educated CNAB on resident #1 on interventions. Educated CNAC on resident #2 on intervention. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; A Quality review that contains look period of 60 days was completed on to ensure residents with that the care plans, kardex and interventions are in place. Issues or concerns were addressed as they were identified. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Director of Clinical Services/Designee re-educated the licensed nurses and certified nursing assistants on the components of this regulation with an emphasis on; management policy and procedure, Care plan and kardex to be updated with interventions, intervention to be in place. During clinical morning meeting Director of Nursing/Designee will review resident with to ensure care plan, kardex and intervention in place. Newly hired licensed nurses and certified nursing assistants will receive education in orientation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, l.e., what quality assurance program will be put in place; The facility Director of Clinical Services/designee will conduct a weekly audit of 5 residents to ensure interventions are care planned, kardex updated and intervention in place weekly x 4 weeks, and then every 2 weeks x 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met and recommends moving to quarterly monitoring by the Divisional Director of Clinical Services when completing their systems review.
Failure to Timely Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of unknown source and serious bodily injury within the prescribed timeframe for a resident. The facility's policy requires that any employee or contracted service provider who witnesses or has knowledge of an act of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, must report such information immediately, but no later than 2 hours after the allegation is made if it involves abuse or results in serious bodily injury. In this case, the resident was found with bruising on the left hip, thigh, and groin area, and an acute left femoral fracture was diagnosed. The incident was identified on the evening of 5/28/24, but the preliminary report was not submitted to the State Survey Agency until 48 hours later, on 5/30/24. The resident involved had a history of senile degeneration and moderate dementia with behavioral disturbance, which may have contributed to the incident as it was speculated that the resident attempted to get out of bed unassisted. The LPN was notified of the bruising and took immediate steps to assess the resident, notify the Power of Attorney, MD, Hospice, and the Assistant Director of Nursing, and obtain witness statements. However, despite these actions, the report to the State Survey Agency was delayed, resulting in a deficiency finding. The Regional Nurse Consultant and the Assistant Director of Nursing confirmed the timeline of events and the delay in reporting the injury.
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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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