Aviata At Seminole
Inspection history, citations, penalties and survey trends for this long-term care facility in Seminole, Florida.
- Location
- 9393 Park Blvd, Seminole, Florida 33777
- CMS Provider Number
- 105895
- Inspections on file
- 30
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Aviata At Seminole during CMS and state inspections, most recent first.
Several cognitively intact residents were not informed or involved in decisions regarding changes to their medications, including psychotropic and pain medications. Residents only became aware of these changes after experiencing symptoms or upon inquiry, and medical records lacked documentation of resident participation in care planning. Staff interviews confirmed inconsistent communication practices, and facility policies requiring resident notification were not followed.
Multiple environmental deficiencies were observed, including unresolved bio-growth in shower areas and unrepaired fixtures in resident rooms. Staff reported issues verbally, but lack of systematic tracking and documentation led to persistent problems. The facility's reliance on informal communication and absence of cleaning and maintenance logs contributed to the failure to maintain a clean and safe environment.
Surveyors found that staff did not consistently follow infection prevention and control protocols, including failing to use PPE when entering rooms of residents on contact precautions, improper storage of medical equipment and clean linen, and unclear or missing precaution signage. Staff interviews revealed confusion about infection control policies and inconsistent application of procedures.
A resident with multiple medical conditions and prescribed medications was observed using marijuana and returning to the facility smelling of the substance. Despite staff awareness and complaints, the resident's provider and medical director were not notified of the drug use, contrary to facility policy requiring notification of changes in condition. Staff interviews revealed confusion about reporting responsibilities, and the care plan did not address illicit drug use or provider notification.
Surveyors found unsanitary conditions, including biogrowth in resident rooms and common areas, and persistent marijuana odors linked to a resident who smoked outside and returned smelling strongly of marijuana. Staff and administration lacked clear policies and consistent procedures for cleaning, biogrowth removal, and odor management, resulting in unresolved environmental concerns.
Two CNAs repeatedly neglected and verbally mistreated multiple residents, leaving them soiled, failing to provide timely hygiene care, and making demeaning comments. Several residents, all with significant care needs, reported being ignored, not cleaned properly, and spoken to disrespectfully. Staff interviews confirmed that these CNAs avoided care duties, were verbally aggressive, and left residents unattended, resulting in a pattern of neglect and emotional distress.
Two CNAs engaged in neglectful and verbally abusive behavior toward multiple residents, including leaving them in soiled briefs, failing to provide proper hygiene, and making derogatory comments. Several residents, many with significant care needs, reported being ignored or made to feel like a burden, while staff interviews confirmed a pattern of unprofessional conduct and lack of timely care. The issues were known among staff but not effectively addressed by management, resulting in ongoing neglect and mental abuse.
Two residents' grievances were not properly investigated or documented, with one resident's complaint about staff behavior during care not resulting in a thorough investigation or communication of outcomes, and another resident being left in feces for an extended period without timely intervention or proper reporting. The facility failed to follow its grievance policy, including requirements for investigation, documentation, and communication.
A resident was found by a CNA to be covered in feces after reportedly requesting assistance for several hours, indicating a lapse in care. Although the incident was documented internally and discussed with nursing staff, the facility failed to report the allegation of neglect to the required state agencies as mandated by policy and federal regulations.
Two residents experienced deficiencies in the facility's grievance process, including lack of proper investigation, documentation, and communication regarding their complaints. One resident did not receive follow-up after reporting inappropriate staff behavior, while another was left in soiled conditions for an extended period without timely care or proper reporting. Staff interviews revealed confusion about responsibility for grievance resolution, and required documentation was incomplete or missing.
A resident who was totally dependent on staff for toileting was found covered in feces after reportedly being left unassisted for several hours, despite requesting help. The incident was documented by staff and reported internally, but the required notification to state agencies was not made, as acknowledged by the facility's administrator.
Several residents assessed as needing constant supervision while smoking were observed smoking unsupervised in unsafe areas near busy roads and driveways, despite care plans and facility policy requiring supervision. Staff interviews revealed confusion over assessment procedures, inconsistent documentation, and inadequate oversight of smoking materials, resulting in residents smoking without the required supervision.
Multiple residents reported delays in call light response and insufficient assistance with care needs, with staff and LPNs confirming high resident-to-staff ratios and frequent short staffing, especially during certain shifts. Observations showed call lights going unanswered while staff were present, and grievances about slow response times remained unresolved. The facility lacked a formal staffing policy and did not have set expectations for call light response times.
The facility did not consistently ensure that controlled medications were accurately reconciled and verified by two nurses when added to medication carts, as required by policy. Observations showed that narcotics were added for several residents without a second nurse's signature or documentation of medication strength, and a significant number of narcotic records across multiple medication carts lacked proper validation. Staff confirmed that procedures for double verification were not always followed, resulting in incomplete documentation and failure to maintain proper chain of custody for controlled substances.
The facility did not ensure accurate reconciliation and accounting for controlled medications, as narcotics were added to medication carts without required second nurse verification and medication strengths were not documented. Despite staff education on proper procedures, audits revealed a high percentage of records lacking a second nurse's validation, and the QAPI process failed to identify or address these deficiencies.
Multiple residents were observed smoking in unsafe, unsupervised areas near busy roads and parking lots, contrary to facility policy requiring designated, supervised smoking areas. Despite care plans and assessments indicating a need for constant supervision, residents were allowed to sign out on LOA and smoke without oversight. Staff interviews revealed confusion about policy implementation, errors in assessments, and inadequate communication about smoking safety, resulting in a failure to protect residents as outlined in the facility's smoking policy.
A resident with a history of hemiplegia and dementia reported being dropped during a transfer, resulting in bilateral knee fractures and a transfer to a higher level of care. The facility failed to thoroughly investigate the incident, as the CNAs involved were not interviewed, and the adverse incident reporting protocol was not clearly followed. The resident later expired at the hospital.
A facility failed to provide wound care as per physician orders for a resident with multiple health issues, with several instances of undocumented care. Additionally, call lights for four residents were not answered in a timely manner, with delays ranging from eight to sixteen minutes. Interviews revealed that call lights were often answered late, and staff sometimes turned off lights without addressing residents' needs. The facility lacked a specific policy on call light response times, contributing to the deficiency.
A resident with multiple medical conditions, including diabetes, was found with long, discolored fingernails and inconsistent shower documentation. Interviews revealed confusion among staff about nail care responsibilities, with a gap in podiatrist services due to a transition. The DON confirmed missing shower sheets and lack of specific nail care documentation, contributing to the deficiency.
A resident with severe cognitive impairments was observed scooting on the floor and left unattended in the hallway. Additionally, the resident was found isolated and sleeping in the activities room, contrary to her care plan goals for social engagement. Staff interviews confirmed that the resident's condition and placement were not managed according to expected standards.
A resident with severe cognitive impairment and difficulty walking was observed with his feet hanging off the edge of his bed on multiple occasions. Despite complaints and staff awareness, no action was taken to provide a suitable bed, revealing a lack of communication and follow-through among staff.
The facility failed to ensure accurate Level I PASRR documentation for four residents, leading to incomplete records of their mental health diagnoses. The ADON and SSD were unsure about marking certain diagnoses, resulting in inaccuracies.
The facility failed to develop and implement person-centered care plans for two residents, one with communication needs due to a language barrier and another with an active DNR order. Staff inconsistently used translator services and relied on another resident for translation, while the care plan for the resident with a DNR order lacked any mention of their code status.
The facility failed to update the care plan for a resident who was initially on contact isolation for candida auris and antibiotic therapy for sepsis and pneumonia. The resident's status changed to being colonized with candida auris and no longer on antibiotics, but the care plan was not revised to reflect these changes.
A facility failed to ensure a resident fed by enteral means received appropriate treatment per physician orders. The resident did not receive the prescribed volume of Glucerna and hydration flushes, and staff admitted to not knowing how to use or document the enteral feeding pump settings. Training deficiencies were also noted.
The facility failed to monitor side effects for a resident on psychotropic medications after the resident returned from hospitalization. Despite the facility's policy requiring every shift monitoring, the side effects monitoring was not re-initiated, leading to a lapse in monitoring for potential adverse reactions.
The facility failed to follow proper infection control practices during medication administration for two residents. An LPN allowed an eye dropper to touch a resident's eyelids, and another LPN did not wear a gown while handling a PEG tube for a resident on Enhanced Barrier Precautions. The DON attributed these breaches to the inexperience of the nursing staff.
A resident with multiple health issues developed severe pressure ulcers due to the facility's failure to implement timely preventive measures and proper skin assessments. Despite being at high risk, the resident's condition worsened, and appropriate interventions were delayed.
The facility failed to maintain a medication error rate below 5.00%, resulting in an observed error rate of 11.54%. Errors included a missed dose of Telmisartan for a resident, late administration of Jevity 1.2 via PEG tube for another resident, and improper insulin administration technique for a third resident.
Failure to Involve Residents in Medication Changes and Care Planning
Penalty
Summary
The facility failed to ensure that four cognitively intact residents were informed in advance and allowed to participate in changes to their person-centered plan of care, specifically regarding medication adjustments. Multiple residents reported that their medications, including psychotropic and pain medications, were changed or discontinued without prior discussion or notification. Interviews revealed that residents only became aware of these changes after experiencing symptoms or upon inquiry, rather than through proactive communication from staff. Documentation in the medical records did not show evidence that residents were involved in or informed about these medication changes. For example, one resident with a history of major depressive disorder, anxiety, and bipolar disorder was not informed about the gradual dose reduction and discontinuation of several psychotropic medications, including Clonazepam and Seroquel. The resident only learned of the changes after noticing symptoms and speaking to nursing staff. Another resident with severe depression and anxiety experienced a reduction in Clonazepam dosage without prior notification, resulting in emotional distress. Similarly, a resident with chronic pain and anxiety had multiple medication changes, including the discontinuation and re-initiation of pain medications, without being consulted or informed about the reasons for these changes. Staff interviews confirmed that there was no consistent process for documenting or ensuring resident involvement in medication changes. The facility's own policies required notification of residents and their representatives when significant changes to treatment occurred, but these procedures were not followed. The lack of communication and documentation was acknowledged by facility leadership, who noted that the forms used for psychiatry notes did not include a section for resident notification or involvement in care planning.
Failure to Maintain Clean and Safe Environment Due to Inadequate QA and Maintenance Tracking
Penalty
Summary
The facility failed to maintain a clean, sanitary, and safe physical environment as required, as evidenced by multiple observations and staff interviews. During a survey, black growth was observed on the floor of a shower room, which a CNA had previously noticed and reported to a nurse, but the issue remained unresolved. The Housekeeping Director confirmed that while the shower room equipment had been pressure washed, there was no documentation or logs to verify when this cleaning occurred. Additionally, the facility lacked a system or log for tracking rooms or items needing cleaning, relying instead on direct verbal reports to the Housekeeping Director. Further deficiencies were identified in the maintenance of resident rooms, including loose sinks, loose toilets, and damaged bed lamination. The Maintenance Director was unaware of some of these issues, despite residents having reported them directly to him. Review of work orders did not show documentation for all reported problems, and the Maintenance Director admitted that he often could not enter work orders immediately when residents reported issues in passing. This lack of timely documentation and follow-up resulted in unresolved maintenance concerns. Interviews with the NHA and Regional President revealed that the facility's process for ensuring environmental cleanliness and maintenance relied heavily on informal communication and random checks, rather than systematic tracking and documentation. Staff were expected to report issues into the facility's maintenance system, and while training on this process had been provided, there were still gaps in execution. As a result, several environmental deficiencies persisted, including unresolved bio-growth in shower areas and unrepaired fixtures in resident rooms.
Inconsistent Infection Control Practices and PPE Use
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices across five of six facility halls. Residents on contact precautions were not consistently identified with appropriate signage, and staff did not always use required personal protective equipment (PPE) when entering rooms of residents on contact precautions. For example, staff were seen entering rooms of residents with C. difficile and other transmissible infections without donning gowns or gloves, and some staff believed PPE was only necessary during close care, contrary to facility policy. Additionally, contact precaution signs were missing or obscured on some doors, and staff were unclear about which residents required precautions. Improper storage of medical and personal care equipment was also noted. Nebulizer and oxygen masks were left uncovered on bedside tables without appropriate storage bags, and an open, unlabeled water bottle with a used washcloth was found on a hallway railing. Linen carts intended for clean linen storage contained inappropriate items such as bottles of cleaner, pens, air freshener, perineal/body wash, and an open can of soda, which staff acknowledged should not be stored with clean linen. Interviews with staff confirmed a lack of understanding and inconsistent application of infection control policies, particularly regarding when to use PPE and how to store equipment and supplies. Staff also reported confusion between contact precautions and enhanced barrier precautions, and acknowledged that education on infection control may not be clear enough. Facility policies reviewed by surveyors outlined requirements for signage, PPE use, and storage practices, but these were not consistently followed in practice.
Failure to Notify Physician of Resident's Illicit Drug Use and Potential Medication Interactions
Penalty
Summary
The facility failed to notify and consult with a resident's physician regarding the resident's known use of illicit drugs, specifically marijuana, despite the potential for medication contraindications. The resident, who had diagnoses including Parkinson's disease, chronic kidney disease, seizures, and cannabis abuse, was observed multiple times smelling of marijuana and admitted to smoking it outside the facility. Staff interviews revealed that while some staff reported the resident's marijuana use to supervisors or administration, none notified the resident's provider or medical director as required by facility policy. Documentation showed that the resident was prescribed several medications, including gabapentin, lacosamide, levetiracetam, and trazodone, all of which could have potential interactions with marijuana. The care plan identified the resident as a smoker and included interventions for unsafe smoking practices, but did not address the use of illicit substances or the need for provider notification. Staff members expressed uncertainty about their responsibilities, with some believing that once a resident signed out on a leave of absence, they were not responsible for actions taken outside the facility, and others assuming that reporting to a supervisor was sufficient. Both the nurse practitioner and medical director confirmed that they had not been informed of the resident's drug use, and stated that they would expect to be notified of such incidents to prevent possible medication interactions. The facility's policy required prompt notification of the physician and resident representative when there is a change in status or condition, but this was not followed in the case of the resident's ongoing marijuana use.
Failure to Maintain Clean, Sanitary Environment and Address Odors
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in multiple areas, as evidenced by the presence of biogrowth and unsanitary conditions in both a common room and two resident rooms. Observations revealed multiple gray and black spots of biogrowth on the back wall and floor of a resident closet, as well as stained floors with brown and black substances. In the Day Room, two ceiling air vents were surrounded by peeling paint with black areas visible underneath, indicating moisture and possible mold. Staff interviews indicated that while deep cleaning was reportedly performed monthly, there was no clear checklist or policy for the removal of biogrowth, and responsibilities for cleaning and reporting were inconsistently understood among housekeeping and maintenance staff. Additionally, the facility did not address persistent odors related to a resident who regularly returned from outside smelling of marijuana. The resident was observed smoking marijuana in the parking lot and later in his room, which had a strong odor of marijuana. Staff, including CNAs and LPNs, reported the smell and concerns to administration, but no effective action was taken. Staff expressed uncertainty about their ability to intervene when a resident returned from a leave of absence smelling of marijuana, and there was no policy provided for the removal of odors. Interviews with facility leadership, including the Director of Maintenance, Nursing Home Administrator, and Director of Nursing, revealed a lack of awareness and oversight regarding both the biogrowth and odor issues. The Director of Maintenance was unaware of the biogrowth in the resident closet and could not explain discrepancies in cleaning records. The Nursing Home Administrator had not recently inspected the affected room and was unaware of any cleaning checklist or policy for biogrowth removal. The Medical Director stated that providers should be notified if a resident's room smelled of marijuana, but this was not consistently done. The facility did not provide policies for the removal of biogrowth or odors when requested.
Neglect and Verbal Mistreatment by CNAs
Penalty
Summary
Multiple residents were subjected to neglect and verbal mistreatment by two certified nursing assistants (CNAs), identified as Staff A and Staff B. Residents reported being left in soiled briefs for extended periods, not being cleaned properly during care, and being spoken to in a disrespectful and demeaning manner. One resident, who was dependent on staff for all activities of daily living due to significant physical and cognitive impairments, described being left saturated with menstrual blood and not being wiped during care. This resident also reported that the CNAs made derogatory comments about her and other residents, including discussing their weight and making negative remarks about their children. Other residents corroborated these accounts, stating that the CNAs were rude, did not provide timely assistance, and made them feel like burdens when they requested help. Additional residents described similar experiences, including being left soiled, not being repositioned or assisted out of bed as requested, and being ignored when call lights were activated. Some residents reported that the CNAs would only change them once per shift, regardless of need, and would talk about other residents and staff in a negative manner while providing care. Staff interviews further supported these claims, with several staff members stating that Staff A and Staff B were often unprofessional, verbally aggressive, and would avoid caring for certain residents. Staff also reported that meal trays were left in front of residents for extended periods and that the CNAs would disappear during critical care times. The facility's own policy defined neglect as the failure to provide necessary goods and services to avoid physical harm, mental anguish, or emotional distress, including not providing timely toileting and hygiene care. The policy also required staff to report any allegations of abuse or neglect immediately. Despite these policies, the behaviors of Staff A and Staff B persisted over time, affecting multiple residents on the same unit. The neglect and verbal mistreatment were corroborated by resident interviews, staff statements, and observations, indicating a pattern of failure to provide adequate care and maintain resident dignity.
Plan Of Correction
F 600 1. Residents #1, 2, 3, 4, 5, 6, 8, and 9 have been assessed by nursing and no adverse effects noted. Psych services offered to residents. Social services continue to offer support services to residents. Activities staff has worked with residents to ensure additional support is provided. There are no adverse effects noted and residents remain safe in the center. Residents interviewed by NHA and all stated that they feel safe and are grateful in the response from administration regarding the situation. 2. Resident interviews completed for residents with above 10. Interview conducted questioned residents if they had witnessed with any other residents or were abused at any time. Skin assessments were completed for residents with a less than 10. Interviews and assessments completed and no additional findings at the time of the interviews and assessments. Any concerns noted in the interviews were reviewed by NHA, and NHA ensured that the concerns were previously addressed. 3. Education was completed with staff in conjunction with posttest and scenarios. Education provided by IDT members to staff. IDT educated by company VP of Risk Management. Education will continue at times of allegations of and during new hire orientation. A sample of residents will be interviewed monthly by IDT to ask questions related to care/treatment and potential concerns. Room rounds continue to be completed five times a week by IDT to ensure resident is monitored and has no concerns. Audit of interviews will be completed by NHA or designee to ensure that there are no outstanding concerns. 4. Audits will be reviewed at the QAA/QAPI meeting monthly for three months or until substantial compliance is achieved. The audits will be presented by the Administrator or designee. Residents will be interviewed monthly by IDT to ask questions related to care/treatment and potential concerns. Room rounds continue to be completed five times a week by IDT to ensure resident is monitored and has no concerns. Audit of interviews will be completed by NHA or designee to ensure that there are no outstanding concerns.
Failure to Protect Residents from Neglect and Mental Abuse by Staff
Penalty
Summary
Surveyors identified a deficiency in the facility's failure to protect residents from neglect and mental abuse by two Certified Nursing Assistants (CNAs), referred to as Staff A and Staff B. Multiple residents reported being left in soiled briefs for extended periods, not being cleaned properly, and being made to feel like a burden when requesting assistance. Residents also described disrespectful and unprofessional behavior from the staff, including name-calling, derogatory comments about residents' weight and abilities, and discussing other residents and staff in a negative manner during care. These actions were corroborated by staff interviews and written statements, which described a pattern of rude, verbally aggressive, and neglectful behavior by Staff A and B, particularly when they worked together. The affected residents had significant care needs, including dependence on staff for toileting, hygiene, and mobility due to conditions such as hemiplegia, aphasia, obesity, and limb amputations. Several residents were cognitively intact and able to articulate their experiences, while others had severe cognitive impairment. The neglect included failure to provide timely and adequate personal care, such as not changing soiled briefs, not cleaning residents properly, and leaving residents unattended in the shower. Some residents reported that their call lights were ignored or turned off without their needs being met, and that they were made to wait for the next shift for care. Staff interviews revealed that the issues with Staff A and B were known among other staff members, who reported the behavior to management and described a hostile work environment. Written statements and interviews indicated that Staff A and B would avoid caring for certain residents, complain openly about their assignments, and disappear during critical care times. Despite these reports, there was a lack of effective follow-up or intervention by facility management prior to the survey, allowing the neglectful and abusive behavior to persist and affect multiple residents on the same unit.
Plan Of Correction
1. Residents #1, 2, 3, 4, 5, 6, 8, and 9 have been assessed by nursing and no adverse effects noted. Psych services offered to residents. Social services continue to offer support services to residents. Activities staff has worked with residents to ensure additional support is provided. There are no adverse effects noted and residents remain safe in the center. Residents interviewed by NHA and all stated that they feel safe and are grateful in the response from administration regarding the situation. 2. Resident interviews completed for residents with above 10. Interview conducted questioned residents if they had witnessed with any other residents or were abused at any time. Skin assessments were completed for residents with a less than 10. Interviews and assessments completed and no additional findings at the time of the interviews and assessments. Any concerns noted in the interviews were reviewed by NHA, and NHA ensured that the concerns were previously addressed. 3. Education was completed with staff in conjunction with posttest and scenarios. Education provided by IDT members to staff. IDT educated by company VP of Risk Management. Education will continue at times of allegations of and during new hire orientation. A sample of residents will be interviewed monthly by IDT to ask questions related to care/treatment and potential concerns. Room rounds continue to be completed five times a week by IDT to ensure resident is monitored and has no concerns. Audit of interviews will be completed by NHA or designee to ensure that there are no outstanding concerns. 4. Audits will be reviewed at the QAA/QAPI meeting monthly for three months or until substantial compliance is achieved. The audits will be presented by the Administrator or designee.
Deficient Grievance Process and Incomplete Investigation of Resident Complaints
Penalty
Summary
The facility failed to ensure a functioning grievance process for two residents, resulting in deficiencies related to the handling and resolution of grievances. In one instance, a resident verbally reported to the Social Service Assistant (SSA) that two CNAs were having personal conversations while providing care, including discussing their likes and dislikes for residents. The concern was relayed to the Administrator In Training (AIT), who assisted in filling out the grievance form but did not conduct an investigation or interview the resident. The Unit Manager (LPN) became aware of the complaint later and spoke to the resident, but there was no documentation of a thorough investigation. The resident reported that no one had come to talk to her about the concern and that she had not received a response from the facility regarding her grievance. Another incident involved a CNA reporting that a resident was found covered in feces and had been left in that condition for an extended period before being changed. The assigned staff member for the investigation was the same LPN/Unit Manager, who documented that the aide responsible was educated about the importance of prompt care. However, the section of the grievance form indicating whether the incident was reportable to the state agency was left blank, and the "Teachable Moment" document in the aide's personnel file was unsigned and not acknowledged by the Human Resource Director. The NHA confirmed that the resident should have been changed at least every two hours and acknowledged that the incident had the potential to be neglect, but the incident was not reported as required. Both cases demonstrate failures in the facility's grievance process, including lack of proper investigation, incomplete documentation, failure to communicate outcomes to residents, and not following reporting requirements for potential neglect. The facility's grievance policy requires prompt resolution, thorough investigation, and proper documentation, but these requirements were not met in the cases reviewed.
Plan Of Correction
F 585 Resident #1 was interviewed regarding the incident, and upon conclusion of the interview, the resident was satisfied with the outcome of the decision made by administration in relation to the submitted grievance. Reportable incident completed regarding this issue on. Additional services offered to the resident to provide additional support. Nursing assessments were completed to ensure there were no adverse effects to the resident. No adverse effects were noted. 2. Grievance log and grievances reviewed for the previous 3 months by NHA and Social Services Director (SSD). There were no other grievances that were found to be reportable events. Resident interviews were completed for residents with above 10 to ensure that there were no outstanding concerns or allegations that were not addressed. Skin assessments were completed for residents with less than 10. No additional findings at the time of evaluation. 3. Grievances are reviewed five times a week by the IDT to ensure a timely response. Grievance log and grievances will be audited weekly by SSD or designee, and NHA or designee to ensure that grievances are completed timely, and allegations of were addressed. This will be an ongoing practice implemented as part of the facility operations. Room rounds continue to be completed five times a week by IDT to ensure the resident is monitored and has no concerns. Education was completed with staff to review the grievance process. Education was provided by IDT members to staff. IDT was educated by the company VP of Risk Management. The grievance process was reviewed at the resident council meeting with residents. The process was reviewed by the Activities Director. Residents confirmed understanding of the process. 4. Audits will be reviewed at the QAA/QAPI meeting monthly for three months or until substantial compliance is achieved. The audits will be presented by the Social Services Director or designee.
Failure to Report Alleged Neglect to Appropriate Agencies
Penalty
Summary
A deficiency was identified when the facility failed to ensure that an allegation of neglect involving a resident was reported to the appropriate agencies as required by federal regulations. The incident involved a resident who was found by a CNA to be covered in feces from the waist down, with some of the feces dried on, indicating the resident had been in that condition for an extended period. The resident reported that he had been asking to be changed all morning and had not been attended to until the afternoon shift began. The CNA who discovered the situation documented the incident and reported it to the nurse and unit manager, and a grievance report was completed. Review of the facility's documentation revealed that a "Teachable Moment" form was created regarding the incident, but it was not properly signed or presented, and the Human Resource Director was unaware of its existence. The section of the grievance report that indicated whether the incident was reportable to the state agency was left unmarked. The facility administrator confirmed that the incident was not reported to the state agency or other required officials, despite acknowledging that the care provided was not appropriate and had the potential to be considered neglect. The facility's policy requires immediate reporting of allegations of neglect to the administrator and appropriate agencies, but this process was not followed in this case. The administrator stated that the standard procedure would involve notifying the clinical team, risk manager, and submitting the incident through the appropriate reporting systems, but confirmed that these steps were not taken for this incident.
Plan Of Correction
1. Resident #9 was assessed by nursing and social services and no adverse effects were noted. Resident remains in the center. Staff B was terminated. Resident #9 interviewed by NHA and resident stated that he felt safe in the center and had no additional concerns at the time of the interview. 2. Resident interviews completed for residents with above 10. Interview conducted questioned residents if they had witnessed with any other residents or were abused at any time. Skin assessments were completed for residents with a less than 10. Interviews and assessments completed and no additional findings at the time of the interviews and assessments. Any concerns noted in the interviews were reviewed by NHA, and NHA ensured that the concerns were previously addressed. 3. Education was completed with staff in conjunction with posttest and education scenarios provided by IDT members to staff. IDT educated by company VP of Risk Management. Education will continue at times of allegations of and during new hire orientation. A sample of residents will be interviewed monthly by IDT to ask questions related to care/treatment and potential concerns. Room rounds continue to be completed five times a week by IDT to ensure resident is monitored and has no concerns. Audit of interviews will be completed by NHA or designee to ensure that there are no outstanding concerns. 4. Audits will be reviewed at the QAA/QAPI meeting monthly for three months or until substantial compliance is achieved. The audits will be presented by the Administrator or designee.
Failure to Ensure a Functioning Grievance Process
Penalty
Summary
The facility failed to ensure a functioning grievance process for two residents, as required by state statute. For one resident, a grievance was verbally communicated to the Social Service Assistant regarding two CNAs having personal conversations while providing care. The grievance form was completed, and the CNAs were identified and verbally educated. However, there was no documentation indicating whether the resident was satisfied with the resolution, and the resident later stated that no one had spoken to her about the concern or provided a response. Interviews with staff revealed confusion about who was responsible for investigating and resolving the grievance, with some staff unaware of the complaint or not participating in the investigation. Another incident involved a resident who was found covered in feces after reportedly waiting for an extended period before being changed. The CNA assigned to the resident was educated about the importance of prompt care, and a "teachable moment" document was placed in the personnel file. However, the form was not signed by the presenter or recipient, and the section indicating whether the grievance was reportable to the state agency was left blank. The resident was totally dependent on staff for toileting, and the care plan reflected this need. The NHA confirmed that the resident should have been changed at least every two hours and acknowledged that the incident could be considered neglect, but it was not reported. Both cases demonstrate a lack of proper documentation, follow-up, and communication with the residents regarding their grievances. The facility did not ensure that grievances were thoroughly investigated, resolved in a timely manner, or that residents were informed of the outcomes, as required by policy and regulation. The absence of clear documentation and communication contributed to the deficiency cited by surveyors.
Plan Of Correction
Resident #1 was interviewed regarding the incident, and upon conclusion of the interview, the resident was satisfied with the outcome of the decision made by administration in relation to the submitted grievance. Reportable incident completed regarding this issue on . Additional services offered to the resident to provide additional support. Nursing assessments were completed to ensure there were no adverse effects to the resident. No adverse effects were noted. Grievance log and grievances reviewed for the previous 3 months by the NHA and Social Services Director (SSD). There were no other grievances that were found to be reportable events. Resident interviews were completed for residents with above 10 to ensure that there were no outstanding concerns or allegations that were not addressed. Skin assessments were completed for residents with less than 10. No additional findings were noted at the time of evaluation. Grievances are reviewed five times a week by the IDT to ensure a timely response. The grievance log and grievances will be audited weekly by the SSD or designee, and NHA or designee, to ensure that grievances are completed timely and that allegations were addressed. This will be an ongoing practice implemented as part of the facility operations. Room rounds continue to be completed five times a week by the IDT to ensure the resident is monitored and has no concerns. Education was completed with staff to review the grievance process. Education was provided by IDT members to staff, and the IDT was educated by the company VP of Risk Management. The grievance process was reviewed at the resident council meeting with residents. Residents confirmed their understanding of the process. Audits will be reviewed at the QAA/QAPI meeting monthly for three months or until substantial compliance is achieved. The audits will be presented by the Social Services Director or designee.
Failure to Report Allegation of Neglect to State Agency
Penalty
Summary
A facility failed to report an allegation of neglect to the appropriate agencies as required by state and federal regulations. The incident involved a resident who was found covered in feces, with evidence indicating he had been left in that condition for several hours. The resident, who was totally dependent on staff for toileting, reported that he had been asking to be changed all morning and had not received assistance until the afternoon shift began. The staff member assigned to the resident during the morning shift had already left the building before the afternoon aide discovered the situation. Documentation in the resident's clinical chart and care plan confirmed his dependence on staff for activities of daily living, including toileting. A "Teachable Moment" form was found in the personnel file of the CNA assigned to the resident, describing the incident and noting that the resident had been left in feces for an extended period. However, the form was unsigned, and the Human Resource Director was unaware of its origin. The afternoon CNA who discovered the resident reported the incident to the nurse and unit manager, and also submitted a written statement and grievance report detailing the neglect. Despite these reports and documentation, the incident was not reported to the state agency as required. The Nursing Home Administrator acknowledged that the care provided was not appropriate and had the potential to be considered neglect, but confirmed that the incident was not reported through the required channels. The process for reporting such allegations was described, but in this case, it was not followed.
Plan Of Correction
1. Resident #9 was assessed by nursing and social services and no adverse effects were noted. Resident remains in the center. Staff B was terminated. Resident #9 interviewed by NHA and resident stated that he felt safe in the center and had no additional concerns at the time of the interview. 2. Resident interviews completed for residents with above 10. Interview conducted questioned residents if they had witnessed any other residents or were abused at any time. Skin assessments were completed for residents with less than 10. Interviews and assessments completed and no additional findings at the time of the interviews and assessments. Any concerns noted in the interviews were reviewed by NHA, and NHA ensured that the concerns were previously addressed. 3. Education was completed with staff in conjunction with posttest and scenarios. Education provided by IDT members to staff. IDT educated by company VP of Risk Management. Education will continue at times of allegations of and during new hire orientation. A sample of residents will be interviewed monthly by IDT to ask questions related to care/treatment and potential concerns. Room rounds continue to be completed five times a week by IDT to ensure resident is monitored and has no concerns. Audit of interviews will be completed by NHA or designee to ensure that there are no outstanding concerns. Mistreated, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law. In the absence of the Executive Director, the Director of Nursing is the designated coordinator. Once an allegation of mistreatment is reported, the Executive Director, as the coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations, including notifications of Law Enforcement if a reasonable suspicion of crime has occurred. A review of Resident #9's clinical chart documented an admission of his diagnosis list included but not limited to Type 2 diabetes. A review of a dated document showed a score of 13, with a comment "Intact response." A review of Resident #9's clinical chart, the Care Plan, documented a focus area: Resident #9 has an ADL (Activity of Daily Living) self-care performance and is at risk for decline. Interventions included: Toilet Use: The resident is totally dependent on staff for toileting. A review of Staff B, Certified Nursing Assistant's... 4. Audits will be reviewed at the QAA/QAPI meeting monthly for three months or until substantial compliance is achieved. The audits will be presented by the Administrator or designee.
Failure to Provide Required Supervision for Residents During Smoking Activities
Penalty
Summary
The facility failed to ensure that residents assessed as needing constant supervision while smoking received adequate supervision. Multiple residents, all identified as smokers with various medical conditions such as COPD, diabetes, muscle weakness, amputations, and cognitive impairments, were observed smoking outside the facility without staff supervision. Some residents were seen smoking on sidewalks adjacent to busy roads and driveways, with traffic moving at high speeds, and in areas not designated as safe smoking locations. Several residents had access to lighters and cigarettes, contrary to facility policy requiring these items to be stored by staff. Record reviews revealed that these residents had care plans and smoking assessments indicating a need for constant supervision while smoking. However, staff interviews and observations confirmed that residents were allowed to sign out on Leave of Absence (LOA) and smoke unsupervised in potentially hazardous areas. The facility's own policies required supervision for residents assessed as needing it, but staff reported confusion and errors in completing smoking assessments, and there was a lack of clear communication regarding safe smoking locations and supervision requirements. Some residents had not signed the required smoking policy agreement, and documentation of LOA times was inconsistent with actual resident whereabouts. Staff interviews further revealed that the facility struggled to keep track of residents' smoking materials and LOA cards, and that supervision during smoking times was inconsistent, sometimes pulling aides away from other resident care duties. The facility's designated smoking policy and procedures were not consistently followed, leading to unsupervised smoking by residents who required supervision according to their assessments and care plans.
Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident interviews, staff interviews, and direct observations. Several residents reported untimely responses to call lights, with one resident stating she often received incontinence care only once during the first shift and had to wait extended periods for assistance. Another resident described being left in a hallway for two hours after requesting help to return to bed, and others confirmed that staff frequently cited being short-handed as the reason for delays. Staff interviews corroborated these accounts, with CNAs and LPNs reporting high resident-to-staff ratios, feelings of being overwhelmed, and an inability to provide timely care due to insufficient staffing, especially during certain shifts such as 3-11 p.m. Observations by surveyors further supported these concerns. On multiple occasions, call lights were observed to be active for extended periods while staff were present in the area but did not respond promptly. In one instance, a bathroom alarm was sounding while a unit manager sat at the nurse's station and a CNA walked past the room without responding, indicating a lack of immediate action to resident needs. The resident council president and other residents also reported that staff often disappeared from the floor during evening shifts and that there were fewer CNAs than expected, leading to longer wait times for assistance. A review of facility records revealed unresolved grievances related to call light response times, with at least one resident stating her complaint had not been addressed or followed up on. The staffing coordinator confirmed that CNA assignments could reach up to 12 residents per CNA, and nurses could have up to 40 residents, though typically had 25-31. The facility did not have a formal staffing policy, and while call light audits and room rounds were being conducted, there was no established expectation for response times. The combination of high resident-to-staff ratios, lack of prompt response to call lights, and unresolved grievances demonstrates the facility's failure to ensure sufficient staffing to meet resident needs.
Failure to Ensure Accurate Reconciliation and Verification of Controlled Medications
Penalty
Summary
The facility failed to maintain an accurate system for reconciliation and accounting of controlled medications across four out of six sampled medication carts. Observations revealed that narcotics were added to medication carts for multiple residents without the required verification by a second nurse. In several instances, narcotic cards lacked documentation of medication strength, and the necessary second nurse signature was missing on both the narcotic cards and the Shift Change Controlled Substance Inventory Count Sheets. These deficiencies were observed during medication cart checks on multiple hallways, with staff confirming that they had received education on the correct procedures, which included double signatures for receiving and discontinuing narcotics. Further review of narcotic books across all hallways showed a significant proportion of Medication Monitoring / Control Records were not initialed or validated by a second nurse, with non-compliance rates ranging from 36% to 77% depending on the hallway. Staff interviews confirmed that the process for counting and documenting controlled substances was not consistently followed, and that the facility's policy did not explicitly require two nurse initials on individual narcotic Medication Monitoring / Control Records. Despite education and audits, the required verification steps were not reliably performed, leading to incomplete documentation and lack of proper chain of custody for controlled substances. The facility's policies outlined procedures for the acceptance, counting, and disposal of controlled drugs, including the requirement for two nurses to open and reconcile pharmacy deliveries and to count controlled substances at shift change. However, observations and record reviews demonstrated that these procedures were not consistently implemented in practice. The lack of adherence to established protocols resulted in discrepancies in the documentation and verification of controlled medications, as evidenced by missing second nurse signatures and incomplete records.
Failure to Ensure Accurate Controlled Substance Reconciliation and QAPI Oversight
Penalty
Summary
The facility failed to establish and implement an effective Quality Assurance and Performance Improvement Program (QAPI) that ensured accurate reconciliation and accounting for all controlled medications across four out of six sampled medication carts. Observations revealed that narcotics were added to medication carts for multiple residents without the required verification by a second nurse, as evidenced by missing second nurse signatures on narcotic cards and inventory count sheets. Additionally, the strength of each medication was not documented on the narcotic cards, further compromising the accuracy of controlled substance records. Staff interviews confirmed that nurses had received education on proper narcotic management, including the requirement for double signatures when receiving narcotics from the pharmacy and when discontinuing or removing narcotic cards. Despite this, the observed practice did not align with the facility's policy or the education provided, as the necessary second nurse verification was consistently absent. Audits of the narcotic books across multiple hallways showed a significant percentage of Medication Monitoring / Control Records lacking a second nurse's validation, with rates ranging from 36% to 77% depending on the hallway. Further review indicated that the facility's QAPI process did not effectively identify or address these ongoing deficiencies. Although the QAPI plan outlined systematic analysis and interdisciplinary participation, the actual implementation failed to ensure compliance with controlled substance handling procedures. Staff acknowledged that the process for counting and documenting controlled substances was not being followed as required, and that the QAPI process did not detect or resolve these issues prior to surveyor identification.
Failure to Provide Safe, Designated Smoking Areas and Supervision
Penalty
Summary
The facility failed to follow its own smoking policy by not providing a safe, designated smoking area for nine of 27 sampled residents. Observations revealed that multiple residents were smoking on the sidewalk or driveway adjacent to busy roads and parking lots, rather than in a designated, supervised area as required by facility policy. Several residents were seen in potentially hazardous locations, such as crossing multiple lanes of traffic or sitting near high-traffic areas, without staff supervision or the required safety equipment. Some residents were also found in possession of lighters and cigarettes, despite the policy stating that such materials should be stored by the facility. Record reviews showed that many residents had care plans and smoking assessments indicating they required constant supervision while smoking, yet they were allowed to sign out on a Leave of Absence (LOA) and smoke unsupervised in unsafe areas. In some cases, the documentation on the LOA sign-out sheets did not match the observed times residents were outside smoking, indicating a lack of accurate tracking. Additionally, at least one resident had not signed the required Smoking Agreement/Notice of Policy, and staff interviews revealed confusion and inconsistency in the implementation of the smoking policy, including errors in smoking assessments and a lack of communication about safety concerns related to smoking near the road. Interviews with staff and residents highlighted further issues, such as staff being pulled from other duties to supervise smoking breaks, leading to delays in resident care. Some staff were unaware of the specific safety risks associated with residents smoking near busy roads, and there was a lack of clear guidance provided to residents about where they could safely smoke. The facility's failure to enforce its smoking policy and ensure proper supervision and designated smoking areas directly contributed to the observed deficiencies.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident who was transferred to a higher level of care. The resident, who had a history of hemiplegia, hemiparesis, and dementia, reported to a registered nurse that he was dropped while being transferred from his bed to a wheelchair. The nurse conducted a head-to-toe assessment and notified the nurse practitioner and the Director of Nursing (DON). However, the two CNAs involved in the transfer denied the fall, and the nurse could not identify them by name. The incident was reported, but the DON did not interview the CNAs and relied on the nurse's report. The resident was transferred to the hospital after complaining of pain and was found to have bilateral knee fractures. The facility's policy required adverse incident reporting for events resulting in fractures or requiring a higher level of care, but it is unclear if this was done. The Director of Clinical Services stated that in such cases, a root cause analysis should be conducted, including staff interviews, but this was not mentioned as having been completed. The resident's hospital records indicated significant pain and bilateral knee fractures, with some fractures of indeterminate age. The facility's policy on adverse incident reporting outlines the need for reporting events that result in fractures or require a higher level of care, but the report does not confirm if this was adhered to. The resident ultimately expired at the hospital, and the facility's failure to thoroughly investigate the incident and adhere to reporting protocols constitutes a deficiency.
Deficiencies in Wound Care and Call Light Response
Penalty
Summary
The facility failed to provide treatment and services in accordance with physician orders for a resident with multiple diagnoses, including acute osteomyelitis, chronic ulcer, peripheral vascular disease, and type 2 diabetes mellitus with a foot ulcer. The Medication Administration Record for November 2024 showed multiple instances where wound care was not documented as completed on specified dates. Observations on November 25, 2024, revealed that the resident's dressing was not changed as per the schedule, and the Director of Nursing confirmed that the facility's expectation was for dressings to be dated and initialed by the nurse. The facility's policy required timely documentation of physician orders, which was not adhered to in this case. The facility also failed to ensure that call lights were answered within a timely manner for four residents. During a tour on November 25, 2024, it was observed that call lights were left unanswered for periods ranging from eight to sixteen minutes, despite staff being present in the vicinity. Interviews with residents revealed that call lights were routinely answered late, sometimes taking over thirty minutes, and staff occasionally turned off the lights without addressing the residents' needs. The Unit Manager and other staff confirmed that call lights should be answered promptly, but acknowledged that busy periods could delay responses. Interviews with the Regional President of Operations and the Director of Clinical Services confirmed that call light response times ranging from eight to sixteen minutes were not timely. They noted that staff were trained on the importance of answering call lights promptly, but acknowledged that busy times could lead to delays. The facility did not have a specific policy related to call light response times, which contributed to the deficiency in timely response to residents' needs.
Deficiency in Nail Care and Shower Services
Penalty
Summary
The facility failed to provide adequate nail care and consistent shower services for a resident, leading to a deficiency in the care of activities of daily living. The resident, who has a history of metabolic encephalopathy, chronic kidney disease, and diabetes insipidus, was observed with long, discolored, and uneven fingernails. The resident's family member also reported that the resident appeared unclean during video chats. Despite being scheduled for showers twice a week, there was no documentation of the resident receiving showers in the past 30 days, and the resident's care plan required nail care on bath days. Interviews with facility staff revealed a lack of clarity and responsibility regarding nail care. A Licensed Practical Nurse stated that nail care was the responsibility of social services, while the Social Service Director indicated that CNAs or nurses should cut fingernails, with podiatrist services reserved for toenails, especially for diabetic residents. The transition to a new podiatrist group had caused a gap in services, and the resident was not scheduled for fingernail care by the podiatrist. The Director of Nursing confirmed that there was no specific documentation for nail care and acknowledged the absence of shower sheets for the resident. The DON stated that the resident had received a shower recently but could not specify the date. The facility's shower sheet form included a section for nail care needs, but there was no evidence that this was completed for the resident. The lack of documentation and coordination among staff contributed to the deficiency in providing necessary care for the resident.
Failure to Ensure Dignified Existence for Resident
Penalty
Summary
The facility failed to ensure a dignified existence for one resident, who was observed scooting around on the floor in her room and into the hallway in front of other residents and staff. The resident, who has severe cognitive impairments and a history of falls, was left unattended on the floor for a period of time before staff assisted her. Additionally, the resident was found in the activities room, separated from other residents, sleeping in a reclined chair with a blanket over her whole body, which was not in line with her care plan goals for social and cognitive engagement. Interviews with staff revealed that the resident was care planned to put herself on the floor, but staff did not promptly assist her. The Activities Director admitted to placing the resident in the activities room but did not ensure she was engaged or comfortable. The Director of Nursing and the Nursing Home Administrator both acknowledged that the resident's condition and placement were unacceptable and not in accordance with the expected standards of care. The resident's care plan included interventions to ensure activities were compatible with her physical and mental capabilities, but these were not followed, leading to the deficiency.
Failure to Provide Appropriate Bed for Resident
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident, specifically regarding the provision of an appropriate bed. Resident #44, who has a history of difficulty walking and severe cognitive impairment, was observed on multiple occasions with his feet hanging off the edge of his bed. Despite the resident's complaints and the staff's awareness of the issue, no action was taken to provide a suitable bed. The resident had been using an air mattress, which was initially provided due to a wound that had since resolved, making the air mattress unnecessary and inappropriate for his current needs. Interviews with staff, including a CNA, the ADON, and the DON, revealed a lack of communication and follow-through regarding the resident's bed size issue. The CNA acknowledged the problem but did not escalate it appropriately. The ADON was unaware of the need to change the mattress, and the DON admitted that the facility did not measure residents for mattress size and relied on staff to report such issues. The Regional Nurse Consultant confirmed that there was no specific policy for mattress sizing, and the standard of care was not met in this case.
Inaccurate PASRR Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate Level I Preadmission Screening and Resident Review (PASRR) for four residents. Resident #43 was admitted with multiple diagnoses including undifferentiated schizophrenia, unspecified dementia, and major depressive disorder. However, the PASRR assessment did not reflect the dementia diagnosis. The Assistant Director of Nursing (ADON) and the Social Services Director (SSD) were responsible for updating PASRRs but were unsure if dementia should be marked, leading to inaccuracies in the PASRR documentation for Resident #43. Resident #68 was admitted with primary and secondary diagnoses of panic disorder, anxiety, insomnia, major depressive disorder, and unspecified psychosis. The PASRR Level I for Resident #68 did not have items checked for mental illness/diagnoses, despite the resident's medical records and psychiatric notes indicating significant mental health issues. The Nursing Home Administrator (NHA) confirmed that the PASRR was incomplete regarding diagnoses. Resident #6 was admitted with a primary diagnosis of end-stage renal disease and secondary diagnoses including bipolar disorder, schizoaffective disorder, and homicidal ideations. The PASRR Level I did not reflect these mental health diagnoses. Similarly, Resident #36 was admitted with diagnoses of bipolar disorder, major depressive disorder, and unspecified dementia with psychotic disturbance, but the PASRR Level I only noted bipolar disorder and major depressive disorder. The ADON confirmed the PASRR was incomplete and did not include all relevant diagnoses.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a person-centered care plan to meet the communication needs of a resident who primarily spoke Spanish. Despite the resident's severe cognitive impairment and preference for Spanish, the care plan did not include any focus, goal, or interventions related to communication. Staff often relied on the resident's roommate to translate, which is against the facility's policy, and there was inconsistent use of translator services among staff members. The Director of Nursing acknowledged that using another resident for translation, especially for medical information, was not appropriate, and staff should use the translator services provided by the facility. Additionally, the facility did not develop a care plan related to the code status for another resident who had an active Do Not Resuscitate (DNR) order. The resident was admitted with a primary diagnosis of respiratory failure, and the care plan lacked any mention of the resident's code status. The Minimum Data Set (MDS) Coordinator admitted that a care plan should have been developed for the resident's code status but was unable to explain why it was not done. The facility's policies and procedures require an individualized person-centered plan of care to be established by the interdisciplinary team with the resident and/or their representative. However, the facility failed to adhere to these policies, resulting in deficiencies in communication and care planning for the residents involved.
Failure to Update Care Plan for Resident
Penalty
Summary
The facility failed to review and revise the care plan for one resident out of the sampled thirty-nine residents. Resident #87 was initially admitted with diagnoses including candidiasis and pneumonia. The care plan indicated that the resident had candida auris and was on contact isolation, and later, antibiotic therapy for sepsis and pneumonia. However, the care plan was not updated to reflect the resident's current status of being colonized with candida auris and on enhanced barrier precautions, nor was it updated to show that the resident was no longer on antibiotics for pneumonia or sepsis. The Assistant Director of Nursing (ADON) confirmed that Resident #87 was now colonized with candida auris and on enhanced barrier precautions, and no longer on antibiotics. The MDS Coordinator acknowledged that the care plan should have been updated. The facility's policy requires that the comprehensive plan of care be reviewed, updated, and revised based on changing goals, preferences, and needs of the resident, which was not adhered to in this case.
Failure to Ensure Proper Enteral Feeding and Documentation
Penalty
Summary
The facility failed to ensure that a resident fed by enteral means received appropriate treatment and services per physician orders. Resident #87, who had diagnoses including dysphagia and pneumonia, was observed with an enteral feeding pump set at 65 ml per hour. However, the Medication Administration Record (MAR) indicated that the total volume of Glucerna was not infused to 1200 ml per day as ordered, and the resident did not receive the hydration flushes totaling 800 ml per day. This discrepancy was observed over multiple days, leading to a 10-pound weight gain in 13 days. Staff members, including an LPN and the Unit Manager, admitted to not knowing how to properly use or document the enteral feeding pump settings, and they had not completed the required training on gastrostomy tube (G-Tube) and documentation. The Regional Registered Dietitian confirmed that the enteral feeding pump's total volume was equivalent to 8 days' worth of feeding, indicating that the machine was not being reset or cleared as required. The Assistant Director of Nursing acknowledged that training had been conducted but noted that many new staff members had been hired. The Director of Nursing stated that her expectations were for staff to follow the physician's orders precisely and to seek assistance if needed. The facility's policies and procedures required documentation of medication administration via enteral tube, but this was not followed in Resident #87's case.
Failure to Monitor Side Effects of Psychotropic Medications
Penalty
Summary
The facility failed to ensure side effects monitoring was in place for a resident receiving psychotropic medications. Resident #8, who was admitted with diagnoses including Schizoaffective Disorder, Bipolar type, Parkinson's Disease, Major Depressive Disorder, and Anxiety Disorder, had several psychotropic medications prescribed. The resident's care plan included specific interventions for monitoring side effects of these medications. However, after the resident was hospitalized and returned to the facility, the side effects monitoring was not re-initiated as required by the facility's policy. The Medication Administration Report (MAR) showed that side effects monitoring was discontinued during the hospitalization and was not resumed upon the resident's return, resulting in a lack of monitoring from the readmission date onwards. The Director of Nursing confirmed that the side effects monitoring was not conducted as per the facility's policy. The facility's policy on Medication Management-Psychotropic Medications mandates that residents receiving psychotropic medications should have their behavior and side effects monitored every shift. Despite this, the facility did not adhere to its policy for Resident #8, leading to a lapse in monitoring for potential adverse reactions to the psychotropic medications. This deficiency was identified through record review, interviews, and policy review, highlighting a failure in the facility's medication management and monitoring processes for residents on psychotropic medication regimens.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to provide proper infection control practices during medication administration for two residents. In one instance, an LPN was observed administering eye drops to a resident, during which the tip of the dropper touched the resident's eyelids. The resident struggled to keep their eyes open, and the LPN continued to administer the drops under the same conditions for both eyes. The dropper was then capped and returned to the medication cart without proper sanitization. In another instance, an LPN was observed checking the placement of a PEG tube and administering enteral feedings to a resident on Enhanced Barrier Precautions. The LPN did not wear a gown during contact with the resident's PEG tube, which is against the facility's policy for Enhanced Barrier Precautions. The Director of Nursing acknowledged the breach of infection control practices and attributed it to the inexperience of the nursing staff. The facility's policy on Enhanced Barrier Precautions requires the use of gowns and gloves during high-contact resident care activities, including device care such as PEG tubes. The policy also mandates that staff be trained prior to caring for residents under these precautions. The observed actions of the LPNs were in direct violation of these established protocols, leading to the identified deficiencies.
Failure to Prevent Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper and timely interventions to prevent pressure ulcers for a resident. The resident, who had multiple diagnoses including severe protein-calorie malnutrition, congestive heart failure, and unspecified dementia, was admitted with excoriation on the sacrum and mushy bilateral heels. Despite being at high risk for skin breakdown, as indicated by a Braden Scale score that decreased from 15 to 12 over a two-week period, the facility did not implement adequate preventive measures in a timely manner. The resident's family expressed concerns about the resident's pressure sores and the lack of appropriate bedding, which was only addressed after the sores had developed further. Observations revealed that the resident had a sacral open area and a stage 4 pressure injury on the left lateral malleolus. The resident was found in a low air loss mattress only after the pressure sores had worsened. The wound care provided included cleansing and dressing the wounds, but the resident's indwelling catheter was not secured properly, causing additional skin damage. The facility's documentation showed that the resident's skin condition was not adequately monitored, and preventive measures such as pressure-relieving devices and nutritional support were delayed. Interviews with the Director of Nursing and a review of the facility's policies indicated that the facility did not follow its own protocols for skin assessment and prevention of pressure ulcers. The DON acknowledged the need for better skin assessment and immediate education for staff. The facility's policies required a total body evaluation upon admission and weekly thereafter, but these were not effectively implemented, leading to the resident's deteriorating skin condition and the development of severe pressure ulcers.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was less than 5.00%, resulting in an observed error rate of 11.54%. During medication administration, three errors were identified among three residents. For Resident #79, Staff C, LPN, failed to administer Telmisartan 20 mg as prescribed for hypertension. For Resident #22, Staff D, LPN, administered Jevity 1.2 via PEG tube later than the prescribed time, contrary to the physician's order to start at 2:00 p.m. and disconnect at 10:00 a.m. For Resident #6, Staff E, LPN, did not prime the insulin needle before administering Novolog, which is against the manufacturer's instructions for use of the insulin pen. The Director of Nursing was informed of the medication error rate of 11.54%. The facility's policy on administering medications, revised in April 2019, states that medications should be administered safely, timely, and as prescribed. The policy also requires that medication errors be documented, reported, and reviewed by the QAPI committee to inform process changes and additional staff training. Despite these policies, the observed errors indicate a failure to adhere to prescribed medication administration protocols.
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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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