Azure Shores Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Miami, Florida.
- Location
- 800 Nw 95th Street, Miami, Florida 33150
- CMS Provider Number
- 105903
- Inspections on file
- 27
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Azure Shores Rehab during CMS and state inspections, most recent first.
Advance directive records for a resident receiving hospice care were conflicting. The chart contained a signed DNR form, but also a Full Code physician order and a signed advance directive acknowledgment indicating Full Code. The care plan still referenced DNR wishes, while a social services note stated there were no advance directives in place. Staff interviews showed inconsistent understanding of the resident’s code status, and the Social Services Director said she was unaware of the Full Code documentation and did not know who entered and signed the note with her electronic signature.
Confidential records were left visible on medication carts, including a bingo card with resident medical information and a paper census with residents’ pictures and medical information. An RN stated she forgot to turn the bingo cards over, and an LPN stated paperwork should be turned over to protect resident information. In a separate event, an RN administered medications to a resident with moderate cognitive impairment in the hallway in front of the nursing station while the resident was being escorted by family members, even though the RN stated meds are to be given in rooms for privacy.
A resident who expired at the facility was inaccurately coded on the Death in Facility MDS as discharged to a short-term general hospital. The MDS Director said she intended to record the resident as deceased, but the system entered code 4 instead, and the DON stated the facility had no written policies or procedures for assessment-related coding.
Oxygen Delivered Above Ordered Rate: Two residents who were dependent on supplemental oxygen were observed receiving oxygen above the physician-ordered rate. One resident with chronic respiratory failure, pneumonia, and dependence on oxygen was found on nasal cannula at 3.25 LPM instead of the ordered 2 LPM with humidification, and another resident with acute and chronic respiratory failure and pneumonia was found at 2.75 LPM instead of the ordered 2 LPM. An RN verified the orders and acknowledged the oxygen was not being administered at the prescribed rate.
A resident receiving hospice services had conflicting advance directive documentation, including a prior signed DNR, a later Full Code acknowledgment, and physician orders reflecting Full Code. The care plan still listed DNR rather than the resident’s current Full Code status, and staff interviews showed inconsistent understanding of the resident’s code status.
Unlocked Soiled Utility Room and Housekeeping Cart Left Accessible: Surveyors observed a second-floor soiled utility room left unlocked on multiple occasions while it contained biohazardous and sharp materials, with a CNA and housekeeping staff exiting without securing the door. Surveyors also observed a housekeeping cart left open and unattended with chemicals visible and accessible. The ADON, RN, and Housekeeping Director stated the room and carts are to be kept locked when unattended, and staff involved said they did not realize the items were left unsecured.
Improper indwelling catheter care was identified for one resident with a UTI history and moderate cognitive impairment. Surveyors observed the catheter tubing looped with urine trapped in the tubing, preventing free flow. The resident had recently received antibiotics for UTI, and the facility’s infection surveillance showed facility-acquired urinary/kidney infections. The facility policy stated catheter tubing should be kept free of kinks and positioned to prevent backflow.
Oxygen was not delivered at the ordered rate for two residents receiving supplemental O2. One resident with chronic respiratory failure and dependence on oxygen was observed at 3.25 LPM despite an order for 2 LPM with humidification, and another resident with acute and chronic respiratory failure was observed at 2.75 LPM despite an order for 2 LPM. An RN verified both orders and acknowledged the flowmeters were set above the prescribed rate; the facility policy required oxygen to be set to the prescribed liter flow.
Improper Storage of Medications in Resident Rooms: Surveyors observed two medicated inhalers at one resident’s bedside and a medicated lotion on another resident’s nightstand. Staff RNs removed the items after notification, and interviews confirmed that medications are supposed to be kept in locked medication areas and not in resident rooms. One resident had COPD and atrial fibrillation with inhaler orders, while the other had no order for the medicated lotion.
A facility failed to keep accurate medical records for two residents. One resident's EMAR showed an antibiotic as administered on days when nursing notes said it was not given, while staff later reported the dose was found and given but the attestation was not in the EHR. Another resident's chart contained conflicting code status documents, including a signed DNR, a Full Code order, and notes indicating Full Code, with staff giving inconsistent accounts of the resident's advance directive wishes.
A resident receiving hospice care had no hospice nursing notes kept in the hospice binder, despite a hospice order and ongoing weekly hospice visits. Surveyors found only the hospice team list, initial certification, and physician orders in the binder, while the hospice RN, LPN, evening supervisor RN, ADON, and DON all stated the notes should be in the binder; the ADON confirmed no notes were present and the hospice nurse said notes were sent to medical records.
QAPI/QAA failed to show an effective plan to correct repeated deficiencies involving F761, F689, F690, and F867. The facility had previously been cited for these issues, and QAA meetings were held quarterly with the Administrator, DON, Medical Director, and other dept heads. During interview, the Administrator and DON said QAPI was used to review whether PIPs were working using quantitative data, but the repeated deficiency concerns remained.
The facility failed to maintain a sanitary and safe environment, with surveyors observing torn window screens, stained furniture, and damaged walls across multiple rooms. Cleanliness issues were prevalent, with soiled floors and mold-like substances in bathrooms and community shower areas. The facility's system for documenting maintenance issues was not effectively utilized, contributing to the ongoing deficiencies.
The facility's menu did not meet the nutritional needs of residents with Dysphagia Advanced, Dysphagia Mechanical Soft, and Dysphagia Pureed diets. A review of the lunch menu revealed no planned vegetable substitution for these diets, despite the inclusion of a Lettuce & Tomato Plate and Pickle Spear for regular diets. The Corporate Food Service Director confirmed the oversight and acknowledged the error in the menu planning.
The facility failed to prepare foods properly, affecting various diets, including Dysphagia Mechanically Altered and Pureed. Observations revealed non-appetizing and tasteless food due to improper storage and preparation methods. Additionally, scrambled eggs with cheese were undercooked and contained unmelted cheese and unidentified black matter, deviating from the standardized recipe. Numerous residents complained about the poor quality, taste, and temperature of the served foods.
The facility failed to prepare food according to the dietary needs of residents on Mechanically Altered and Pureed Diets. Observations revealed that meals were not prepared to the required consistency, with a Ground BBQ Cheeseburger being watery and a Pureed BBQ Cheeseburger containing visible pieces of ground beef. Staff admitted to not receiving proper training on food preparation, and the issue was confirmed by the CFSD.
A resident with lactose intolerance was not provided with a therapeutic diet as required. Despite having a documented restriction of no dairy, the resident was served meals containing milk products, leading to weight loss and malnutrition. The facility failed to obtain a physician's diagnosis and diet order for lactose intolerance, contributing to the deficiency.
The facility failed to meet food safety standards, affecting 104 residents. Observations revealed improper thawing of chicken, unsanitary conditions in the kitchen, and food not held at safe temperatures. Additionally, the facility lacked a working food thermometer, and staff entered food areas without protective gear.
The facility failed to properly dispose of garbage and refuse, affecting all residents. During an observation tour, the surveyor noted open trash containers and littered areas with soiled PPEs, waste materials, and evidence of pests. Despite being informed of a cleanup, a follow-up visit showed the area remained unsanitary. The administration was notified of the health hazard.
A facility failed to meet professional standards of quality when an LPN was observed administering medication with long, artificial nails, violating the facility's policy. Interviews revealed staff confusion and non-compliance with the policy, highlighting a lack of enforcement and communication regarding hygiene standards.
A resident with an indwelling urinary catheter did not receive proper care, as a CNA failed to perform hand hygiene between glove changes and improperly placed the catheter tubing. Additionally, a nephrology consult ordered by a physician was not scheduled, revealing a lapse in communication and follow-through on medical orders.
The facility failed to monitor and document the nutritional intake of a resident with diabetes and dysphagia, leading to significant weight loss. Additionally, the facility inaccurately recorded the weight of a newly admitted resident, placing them at nutritional risk. These deficiencies highlight lapses in documentation and monitoring, impacting residents' health.
The facility failed to follow physician's orders for tube feeding for two residents, resulting in them receiving less than the prescribed amount. Observations showed that the tube feeding was not infusing as ordered, and staff interviews revealed a lack of proper monitoring and documentation. Both residents had significant medical histories, including cerebral infarction and dysphagia.
A facility failed to provide adequate pharmaceutical services, leading to deficiencies in medication administration and documentation. An LPN did not verify a resident's identity, failed to perform hand hygiene, and documented medications as administered when they were not. Controlled medications were not properly managed, with discrepancies in documentation and discontinued medications remaining in the med cart. The facility's policies on medication administration and hand hygiene were not followed, contributing to the deficiencies.
A facility's medication error rate was found to be 28%, exceeding the acceptable threshold of 5%. During a medication pass, an LPN failed to verify a resident's identity and did not administer all scheduled medications, inaccurately documenting them as given. The LPN also neglected to instruct the resident to rinse his mouth after using an inhaler, as required. The DON attributed the errors to the LPN's inexperience and nervousness.
A new LPN at the facility failed to properly dispose of a spilled medication during administration to a resident. Instead of using the designated drug buster, the LPN placed the pill in an uncovered trash bin. The LPN, who had been at the facility for one month, acknowledged the mistake during an interview.
The facility's QAPI/QAA failed to correct repeated deficiencies in maintaining a safe, clean, and homelike environment, tube feeding management, and proper disposal of garbage. These issues, previously cited, were observed again, potentially affecting all 116 residents.
Advance Directive Records Were Conflicting
Penalty
Summary
The facility did not appropriately maintain Advance Directives for one resident receiving hospice services. Resident #101, who had diagnoses including Acute Myeloblastic Leukemia and was documented on the MDS as having moderate cognitive impairment and receiving hospice care, had conflicting code status information in the record. The resident’s electronic health record contained a signed DNR form dated 9/17/2025, while the March 2026 physician order sheets included a Full Code order dated 2/25/2026 and a hospice admission order dated 03/05/2026. An Advance Directive Acknowledgment form dated 02/25/2026 indicated the resident chose Full Code, and a social services note dated 02/27/2026 documented the resident’s code status as Full Code and stated there were no advance directives in place. The resident’s care plan, however, continued to identify DNR wishes and hospice services, with an intervention stating that advance directive wishes would be communicated to pertinent staff and via orders in the medical record. During interviews, the Hospice Social Worker stated they were working on getting the resident to sign a DNR, an LPN stated the resident’s advance directives were Full Code, and the DON stated the resident had a DNR on initial admission but wanted to be Full Code on readmission and signed a Full Code advance directive. The Social Services Director stated she was not aware the resident wanted a Full Code advance directive and did not know who wrote and signed the social services note using her electronic signature. The resident also confirmed wanting a Full Code advance directive, and the hospice nurse stated the resident had an advance directive of Full Code.
Confidential Records Left Visible and Medications Given in Hallway
Penalty
Summary
The facility failed to keep residents’ personal and medical records private and confidential when confidential information was left visible on medication carts and when medications were administered in a public area. On 04/06/2026, a bingo card with a resident’s name and medical information was observed on top of the unattended 400/500 medication cart, and on 04/09/2026, a paper census with residents’ pictures and medical information was observed on top of the unattended first-floor 100-section medication cart. The ADON stated that staff are to ensure documentation containing resident information is stored to prevent visibility to anyone outside the medical care team, and an RN stated she turns bingo cards over for confidentiality, but had forgotten to do so. Staff H stated paperwork should be turned over to protect resident information. The facility also failed to provide privacy during medication administration for Resident #32. On 04/07/2026, Resident #32 was being escorted in a wheelchair by two family members toward the elevator on the second floor when Staff E, RN stopped the resident and administered medications in the hallway in front of the nursing station. The RN stated medications are to be administered in the rooms for privacy, but she gave the medication in the hallway because she was trying to get to the resident before the resident left the floor. Resident #32 had been admitted with sequelae of cerebral infarction, and the quarterly MDS dated 3/16/2026 showed a BIMS score of 8, indicating moderate cognitive impairment.
Inaccurate MDS Coding for Resident Death
Penalty
Summary
The facility inaccurately coded the MDS for one resident whose closed record was reviewed. Resident #128 was admitted to the facility, readmitted, and later expired at the facility, with clinical diagnoses including COPD. However, the Death in Facility MDS Section A dated [DATE] documented the resident as discharged to a short-term general hospital instead of deceased. During interview, the MDS Director stated she intended to record the resident as deceased, but the system registered the entry under code 4 for short-term general hospital. The DON also stated the facility had no written policies or procedures for resident assessment related to coding and that staff relied solely on regulatory guidance rather than facility-developed protocols.
Oxygen Delivered Above Ordered Rate
Penalty
Summary
The facility failed to implement oxygen care plans for two sampled residents who were dependent on supplemental oxygen. Resident #124, with diagnoses including chronic respiratory failure with hypoxia, pneumonia, and dependence on supplemental oxygen, was observed in bed with oxygen via nasal cannula running at 3.25 LPM and no humidification was observed, although the physician's order dated 03/06/2026 directed oxygen at 2 LPM as tolerated every shift for shortness of breath with humidification. Resident #124's care plan, initiated on 09/13/2024 and revised on 02/11/2026, identified a potential for altered respiratory status/difficulty breathing and included oxygen as ordered as an intervention. Resident #13, with diagnoses including acute and chronic respiratory failure with hypoxia and pneumonia, was observed in bed with oxygen via nasal cannula at 2.75 LPM. The physician's order dated 01/16/2026 directed oxygen at 2 liters via nasal cannula as tolerated every shift related to acute and chronic respiratory failure with hypoxia. Resident #13's care plan, initiated on 12/28/2023 and revised on 01/10/2024, identified a potential for altered respiratory status/difficulty breathing and included oxygen as ordered. During the observations, Staff E, RN verified the ordered oxygen rates for both residents and acknowledged that the oxygen was not being administered at the prescribed rate.
Advance Directive Care Plan Not Updated to Match Resident Code Status
Penalty
Summary
The facility failed to update Resident #101’s Advance Directive care plan to reflect the resident’s current code status. Resident #101 was receiving hospice services, had a diagnosis that included Acute Myeloblastic Leukemia, and a quarterly MDS dated 02/10/2026 indicated moderate cognitive impairment. The March 2026 care plan, initiated on 10/09/2025 and revised on 04/07/2026, stated that the resident had advance directive wishes in place as DNR and that wishes would be communicated via order in the medical record. Record review showed conflicting documentation regarding code status. The physician order sheets included a Full Code order dated 2/25/2026 and a hospice admit diagnosis order dated 03/05/2026. An Advance Directive Acknowledgment form dated 02/25/2026 indicated the resident chose Full Code, and a Social Services note dated 02/27/2026 stated the resident’s code status was Full Code and that no advance directives were in place. The EHR also contained a signed DNR form dated 9/17/2025, and staff interviews reflected inconsistent understanding of the resident’s status, with the Hospice Social Worker stating they were working on getting the resident to sign a DNR, while the DON, LPN, and Hospice nurse stated the resident was Full Code.
Unlocked Soiled Utility Room and Housekeeping Cart Left Accessible
Penalty
Summary
The facility did not consistently maintain an environment free of accident hazards in one of two soiled utility rooms and one of three housekeeping carts. On 04/06/2026, surveyors observed the second-floor soiled utility room door unlocked on multiple occasions while it contained biohazardous and sharp materials. Staff F, a CNA, was observed exiting the room and leaving the door unlocked, and Staff J, housekeeping, was also observed exiting the room while the door remained unlocked. The ADON/Infection Preventionist and an RN stated that the soiled utility room door is supposed to be kept locked and accessed with a code for resident safety because items in the room can harm residents. Both Staff F and Staff J stated they did not realize the door was being left open. Surveyors also observed a housekeeping cart left open and unattended on the second floor with chemicals visible and accessible. Staff L, a floor tech, was observed walking away from the cart while it remained unlocked. The Housekeeping Director stated that the facility has three housekeeping carts and that they are to be kept locked when unattended because they contain chemicals. Staff L later stated the cart is to be locked when unattended and acknowledged leaving it unlocked while cleaning.
Improper Indwelling Catheter Tubing Positioning
Penalty
Summary
Failure to provide appropriate catheter care was identified for one resident with an indwelling urinary catheter. During observation, the resident was found in bed with the catheter tubing looped and containing urine, and the tubing was not positioned to allow urine to flow freely. The resident had been admitted and readmitted to the facility and had diagnoses including UTI. The resident’s care plan included interventions for the indwelling catheter, and the MDS indicated moderate cognitive impairment, dependence for toileting hygiene, and an indwelling catheter. The resident’s records showed treatment for UTI, including Ertapenem sodium in March 2026 and Levofloxacin in late March through early April 2026. The Infection Preventionist stated that indwelling urinary catheter tubing should be patent to allow free flow of urine to prevent infection. Facility infection surveillance reports for January and March 2026 documented increases in facility-acquired infections, including urinary tract/kidney infections, and noted the resident received antibiotics for UTI. The facility policy stated that catheter tubing should be kept free of kinks and the drainage bag positioned lower than the bladder to prevent backflow.
Oxygen Delivered Above Prescribed Flow Rate
Penalty
Summary
The facility failed to ensure oxygen was delivered at the prescribed rate for two oxygen-dependent residents. Resident #124 was observed in bed receiving oxygen via nasal cannula at 3.25 LPM, while the physician’s order was for 2 LPM as tolerated every shift with humidification. Resident #124’s record showed diagnoses including chronic respiratory failure with hypoxia, pneumonia, and dependence on supplemental oxygen, and the care plan directed oxygen settings as ordered. When the RN was asked about the oxygen order, she confirmed the order was for 2 LPM and stated the flowmeter was at 3 LPM, adding that she did not know why. Resident #13 was also observed in bed receiving oxygen via nasal cannula at 2.75 LPM, although the physician’s order was for 2 LPM via nasal cannula as tolerated every shift related to acute and chronic respiratory failure with hypoxia. Resident #13’s record showed a history of acute and chronic respiratory failure with hypoxia and pneumonia, was dependent for ADLs, and received oxygen therapy. The RN verified the order for 2 liters per minute and acknowledged that the oxygen was not being administered at the prescribed rate. The facility policy titled Clinical-Oxygen Administration stated that oxygen should be set to the prescribed liter flow.
Improper Storage of Medications in Resident Rooms
Penalty
Summary
The facility failed to properly store medications and biologicals for two residents when surveyors observed medications left in resident rooms instead of being secured in locked storage. Resident #132, who had diagnoses including COPD and atrial fibrillation, was observed in bed with two medicated inhalers inside a plastic bag on the side table next to the bed. Staff D, RN stated that medications are not allowed to be in resident rooms and removed both inhalers after the concern was identified. Record review later showed physician orders for Albuterol Sulfate HFA inhalation aerosol solution and Trelegy Ellipta inhalation aerosol powder for COPD. Resident #116, who also had diagnoses including COPD and atrial fibrillation, had a medicated lotion observed on the nightstand during two separate observations in the room. Staff E, RN removed the lotion after being notified. Record review showed no physician orders for medicated lotions. Interviews with nursing staff indicated that medications are kept in the medication room and carts, residents are not allowed to keep medications in their rooms, and staff are expected to remove any medications observed during rounds. The facility policy stated that medications and biologicals in medication rooms, carts, boxes, and refrigerators are to be maintained in secured, locked locations accessible only to designated staff.
Inaccurate medication and advance directive documentation
Penalty
Summary
The facility failed to maintain an accurate medical record for two residents. For one resident, the record showed an order for Levofloxacin 500 mg daily for 10 days for a wound culture infection, but nursing notes documented that the medication was not administered on two days because the medication was not available. At the same time, the April EMAR contained signatures indicating the medication was administered on multiple dates, and on the two dates when nursing notes said it was not given, the EMAR showed a code for "Other / See Nurse Notes." The wound care LPN observed the resident receiving left heel wound treatment, and the DON later stated that nurses sign an attestation if anything changes with administration. Staff later reported that the medication had been found and given, but the attestation documents were not found in the electronic health record. For the second resident, the record contained conflicting advance directive information. The chart included a signed DNR form and a care plan stating the resident had DNR wishes in place and was receiving hospice services. However, the March physician order sheet also included an order for Full Code, and an Advance Directive Acknowledgment form indicated the resident chose Full Code. A social services note documented that the resident's code status was Full Code and that no advance directives were in place, while the hospice social worker and an LPN also stated the resident was Full Code. The DON stated that the resident had a DNR signed on initial admission and that on readmission the resident wanted to be Full Code and signed a Full Code advance directive, while the DNR remained in the file because it was part of the medical record. The Social Services Director stated she was not aware the resident wanted a Full Code advance directive and did not know who wrote and signed the social services note using her electronic signature. The facility policy on medical record documentation stated that errors should be struck through or corrected in the electronic record.
Hospice Notes Not Kept in Resident Binder
Penalty
Summary
The facility failed to collaborate and coordinate with hospice services for one resident receiving hospice care because hospice nursing notes were not obtained and kept in the resident’s hospice binder since March 2026, despite a physician order for hospice services. The resident was admitted and readmitted with diagnoses including Acute Myeloblastic Leukemia, had moderate cognitive impairment on the quarterly MDS, and had a care plan that included DNR wishes and hospice interventions. The resident also had a physician order dated 03/05/2026 for hospice admission with a diagnosis of unspecified B-cell lymphoma. Surveyors reviewed the resident’s hospice binder at the second-floor nursing station on two occasions and found a hospice team list, initial certification, and physician orders, but no nursing notes or sign-in sheet. The hospice admission RN stated the hospice notes are usually kept in the binder and that the facility nurse would need to speak with the assigned hospice nurse. Facility staff, including an LPN, the evening supervisor RN, the ADON, and the DON, all stated that hospice notes were kept in the hospice binder, yet the ADON confirmed there were no notes for the resident in the binder and indicated notes had not been received since March 2026. The hospice nurse later stated that weekly visits were made and notes were sent to medical records.
QAPI/QAA Failed to Address Repeated Deficiencies
Penalty
Summary
The facility's QAPI/QAA activities failed to demonstrate an effective plan of action to correct repeated deficient practices in several problem areas, including F761, F689, F690, and F867. The report states that these deficiencies had been cited previously during the recertification and relicensure survey with an exit date of 09/26/2024, and that the repeated deficient practices had the potential to affect the 119 residents in the facility at the time of survey. Record review showed the facility's QAPI Plan was revised on January 20, 2026, and described a proactive approach to improving care and resident outcomes. The QAA Committee meeting sign-in sheets dated 01/29/26 showed quarterly meetings with attendees including the Administrator, Medical Director, DON, and other department heads. During an interview on 04/09/26 at 4:40 PM, the Administrator/QAA and DON stated the QAPI team included the medical doctor, DON, department heads, and pharmacist, and that the purpose of QAPI was to discuss continuous quality improvement and review whether Performance Improvement Plans were working using quantitative data. The surveyor informed the Administrator and DON of the repeated deficiency concerns that would be cited, and the [NAME] stated, "We take this as a learning lesson."
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to maintain a sanitary, safe, orderly, and comfortable environment for residents on the first and second residential living floors. During a survey conducted over several days, numerous deficiencies were observed, including torn window screens, stained and worn furniture, and damaged room walls. Additionally, several rooms had non-functional equipment such as light bulbs and air-conditioning units that required maintenance. The surveyors noted that these issues were prevalent across multiple rooms, indicating a systemic problem in maintaining the facility's infrastructure. The surveyors also found significant cleanliness issues, with many rooms having soiled and stained floors, particularly in bathrooms. Some bathrooms had missing baseboards, and there were instances of mold-like substances on ceiling tiles in community shower areas. The presence of heavily soiled air-conditioning filters and stained grout in shower stalls further highlighted the lack of adequate housekeeping and maintenance services. The facility's computerized system for documenting housekeeping and maintenance issues was reportedly not being utilized effectively, as it was unclear whether the system was operational or if staff were using it. This lack of documentation and follow-up on maintenance concerns contributed to the ongoing deficiencies observed during the survey. The findings were confirmed with the facility's Administrator, indicating a need for improved oversight and management of the facility's environment.
Menu Deficiency for Residents with Dysphagia
Penalty
Summary
The facility's menu failed to meet the nutritional needs of 28 residents with physician-ordered Dysphagia Advanced/Dysphagia Mechanical Soft diets and 9 residents with Dysphagia Pureed diets. During a review of the approved menu for a lunch meal, it was noted that there was no planned vegetable substitution documented for these specific diets. The menu included a Lettuce & Tomato Plate and a Pickle Spear for a regular diet, but lacked a suitable vegetable substitution for residents with dysphagia. An interview with the Corporate Food Service Director confirmed that the diets did not have a documented vegetable substitution planned on the approved menu. The CFSD acknowledged the error in the planned menu and indicated that he would seek clarification from the corporation.
Deficiencies in Food Preparation and Quality
Penalty
Summary
The facility failed to prepare foods in a manner that conserves nutritive value, flavor, and appearance for various diets, including Dysphagia Mechanically Altered, Mechanical Soft, Dysphagia Pureed, and Regular Diets. During an observation tour, it was noted that prepared foods were stored in a steamer that was not turned on, resulting in non-appetizing and tasteless food. The breakfast/lunch cook revealed that the food was prepared early in the morning and held under steam heat until lunch, leading to a loss of nutrient content, appearance, and palatability. Numerous residents complained about the poor quality, taste, and temperature of the served foods. Additionally, during a review of the facility's standardized recipe for scrambled eggs with cheese, it was observed that the eggs were undercooked and contained large pieces of unmelted cheese and unidentified black matter. The eggs were not prepared according to the standardized recipe, and the surveyor requested that the egg and cheese entree not be served. The diet census indicated that a significant portion of the resident population could have been served this improperly prepared meal.
Failure to Prepare Mechanically Altered and Pureed Diets Correctly
Penalty
Summary
The facility failed to prepare food in a form designed to meet the individual dietary needs of residents on a Mechanically Altered and Pureed Diet. During an observation of a lunch meal, it was noted that the Ground BBQ Cheeseburger intended for Dysphagia Advanced and Dysphagia Mechanical Soft Diets was watery and thin, lacking palatability and taste. The Corporate Food Services Detain (CFSD) confirmed these findings and acknowledged that the food was not tasted prior to serving. Additionally, the Pureed BBQ Cheeseburger was observed to contain visible pieces of ground beef, indicating it was not pureed to the required smooth consistency. Staff I admitted to not having received education on the proper preparation of pureed foods. The facility's Diet Census indicated that 28 residents were on a Dysphagia Mechanically Altered and Mechanical Soft Diet, and 9 residents were on a Dysphagia Pureed Diet. The surveyor, along with the CFSD, concluded that the foods were not prepared according to physician orders and the facility's Approved Diet Manual. Photographic evidence was obtained to support these findings. The lack of proper food preparation poses a risk of choking and potential aspiration for residents with severe chewing and swallowing problems.
Failure to Provide Therapeutic Diet for Lactose Intolerant Resident
Penalty
Summary
The facility failed to ensure that a therapeutic diet for lactose intolerance was obtained from the attending physician and followed for a resident. During an observation, it was noted that the resident, who appeared underweight and malnourished, was served a breakfast tray containing dairy products despite having a documented dietary restriction of no dairy. The resident reported being lactose intolerant for approximately five years and experiencing weight loss due to receiving meals with milk products. The Corporate Food Service Director confirmed the presence of dairy on the meal tray, despite the tray ticket indicating no dairy. A review of the resident's clinical records revealed no physician diagnosis of lactose intolerance and no corresponding diet order. The resident's care plan documented nutritional problems due to weight loss and lactose intolerance, but the attending physician had not documented a primary diagnosis of lactose intolerance or ordered a lactose-free diet. The resident's weight history showed significant weight loss, and the nutrition assessment indicated severe underweight and protein-calorie malnutrition. The Registered Dietitian noted the lack of a proper diagnosis and diet order, which contributed to the deficiency.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, affecting potentially 104 of the 116 residents who consume food orally. During an initial observation, a large pot of water containing raw chicken was found at 100 degrees Fahrenheit, exceeding the regulatory maximum of 70 degrees Fahrenheit for thawing hazardous foods. The walk-in refrigerator had soiled and damaged shelving, and its fan covers were dusty. Additionally, air-conditioning vents in the food preparation area were covered with a black mold-like substance, and the dish machine area had walls covered with a similar substance. Food on the serving steam table was not maintained at the required temperature of 135 degrees Fahrenheit, with items like sausage patties and pureed scrambled eggs being served at significantly lower temperatures. Further observations revealed that the facility's food thermometer was inaccurate, and there was no alternative available, necessitating the use of a state-issued thermometer. Certified Nursing Assistants were observed entering the food preparation area without proper protective attire, which was noted as a daily occurrence. Cleaning rags and soiled paper towels were improperly stored on clean food preparation surfaces, and a personal cell phone was found on a clean food serving surface, despite previous staff training on this issue.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, potentially affecting all 116 residents. During a kitchen and food service observation tour, the surveyor, along with the Certified Dietary Manager and Corporate Food Service Director, noted that the garbage/trash container had its lid open, with trash spilling into the surrounding area. The area behind the dumpster was heavily littered with soiled PPEs, unidentifiable waste materials, rotting trash, and evidence of insect and rodent activity. The affected area was approximately 25 feet long and 5 feet wide, with a large section of stagnant, foul-smelling garbage at one end. The surveyor immediately notified the administration of the potential health hazard. Despite being informed that the area had been terminally cleaned, a subsequent observation two days later revealed that the garbage/refuse area remained in the same unsanitary condition. The administration was again notified of the ongoing health hazard, and it was noted that incorrect information had been provided by staff during the initial observation.
Failure to Adhere to Professional Standards of Hygiene
Penalty
Summary
The facility failed to ensure that services provided to residents met professional standards of quality, as evidenced by the observation of a Licensed Practical Nurse (LPN) administering medication with long, artificial fingernails. During a medication pass for a resident, the LPN was observed with artificial nails extending about 1 inch past the edge of her fingers, adorned with rhinestones. This was in direct violation of the facility's employee handbook, which prohibits acrylic and gel nails or any other artificial nails for staff with resident care responsibilities. The handbook specifies that nails must be clean, neat, and trimmed to 1/4 inch. Interviews with staff revealed a lack of awareness and adherence to the facility's policy on fingernails. The LPN involved in the incident was unaware of any policy regarding staff fingernails. Another LPN/Unit Manager incorrectly stated that gel nails were permissible if they were short and just past the tip of the fingers, while a Registered Nurse admitted to having nails that extended about 1/2 inch past the fingertip, claiming ignorance of the surveyor's visit. These discrepancies highlight a failure in enforcing and communicating the facility's standards for personal appearance and hygiene, which are crucial for maintaining professional standards of quality in resident care.
Deficiency in Catheter Care and Nephrology Consult Scheduling
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling urinary catheter, leading to potential infection risks and a missed nephrology consult. The resident, who was admitted with multiple diagnoses including chronic kidney disease and a history of urinary tract infections, had a physician's order for catheter care every shift and a nephrology consult. However, during an observation, a CNA did not follow proper hand hygiene protocols while providing catheter care, failing to perform hand hygiene between glove changes multiple times. Additionally, the catheter tubing was improperly placed under the resident's leg, causing discomfort. Furthermore, the facility did not schedule a nephrology consult for the resident despite a physician's order. The DON initially believed the consult had occurred, but it was later revealed that no appointment had been made. The LPN unit manager confirmed that the nephrology consult was ordered due to a high potassium level, but the appointment was not scheduled until the day of the survey. The Social Service Director confirmed that this was the first time she was asked to make the appointment, indicating a lapse in communication and follow-through on the physician's orders.
Deficiencies in Nutritional Monitoring and Weight Documentation
Penalty
Summary
The facility failed to adequately monitor and document the food and supplement intake for a resident with a history of diabetes, dysphagia, and vitamin deficiency. This resident, who was moderately cognitively impaired, experienced significant weight loss over a period of months. Despite having a care plan in place that required monitoring and reporting signs of malnutrition, the facility's documentation was incomplete. The resident's consumption of meals and supplements was inconsistently recorded, with several instances of missing documentation. Interviews with the Registered Dietitian and staff revealed that the documentation process was not thorough, contributing to the oversight in monitoring the resident's nutritional status. Another deficiency was identified in the facility's failure to ensure accurate weight documentation for a newly admitted resident. The resident was initially recorded as weighing 190 pounds, but upon re-evaluation, it was discovered that the resident actually weighed 164 pounds, including the weight of a medical device. This discrepancy was noted during a surveyor's observation, where the resident appeared underweight and expressed concerns about insufficient food intake. The Registered Dietitian confirmed the initial weight was incorrect, placing the resident at nutritional risk. These deficiencies highlight the facility's lapses in maintaining accurate and complete records of residents' nutritional intake and weight, which are critical for ensuring proper care and preventing malnutrition. The lack of accurate documentation and monitoring led to significant weight loss in one resident and an incorrect assessment of another resident's nutritional status, both of which could have serious implications for their health and well-being.
Failure to Follow Physician's Orders for Tube Feeding
Penalty
Summary
The facility failed to ensure that physician's orders for tube feeding were followed for two residents, resulting in deficiencies in their care. Resident #85 was observed with a Glucerna 1.2 tube feeding bottle that was not infusing as ordered, leading to the resident receiving only 1,100 milliliters of tube feeding in 24 hours instead of the prescribed 1,400 milliliters. The resident had a history of cerebral infarction, hemiplegia, dysphagia, and gastrostomy status. The staff did not document the tube feeding stoppage between 2:00 PM and 10:00 AM, and a Licensed Practical Nurse admitted to not calculating the total amount of tube feeding due to bottle changes during shifts. Similarly, Resident #18 was observed with a Glucerna 1.2 tube feeding that was not infusing as per the physician's order, resulting in the resident receiving only 1,000 milliliters instead of the required 1,400 milliliters in 24 hours. This resident also had a history of cerebral infarction, dysphagia, and gastrostomy status, with a severe cognitive impairment. Interviews with staff, including a Registered Nurse and a Registered Dietician, revealed a lack of proper monitoring and documentation of the total amount of tube feeding infused, contributing to the deficiency in care for these residents.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, resulting in multiple deficiencies in medication administration and documentation. For Resident #54, the Licensed Practical Nurse (LPN) did not verify the resident's identity before administering medications, failed to perform hand hygiene, and did not ensure the resident rinsed his mouth after using an inhaler. Additionally, the LPN documented medications as administered when they were not, as confirmed by both the resident and the LPN during interviews. The Director of Nursing (DON) acknowledged that the LPN made a mistake during the medication pass. The facility also failed to properly manage controlled medications. For Resident #54, the Medication Monitoring/Control Log indicated that Oxycodone/APAP was removed from the med cart multiple times, but the Medication Administration Record (MAR) showed it was not administered. Similarly, for Resident #6, Tramadol was discontinued but remained in the med cart for over four months, with no documentation of administration after discontinuation. The DON confirmed that the medication should have been removed from the med cart when discontinued. The facility's policies on administering medications, controlled substances, and hand hygiene were not followed. The policies require verifying the resident's identity using two forms, performing hand hygiene before and after handling medications, and removing discontinued medications from the med cart. The DON acknowledged the lapses in following these procedures, which contributed to the deficiencies observed during the survey.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported error rate of 28% during a medication pass observation. This deficiency was identified during a survey where seven medication errors were noted out of 25 opportunities, specifically affecting a resident with multiple medical conditions including COPD, Type 2 Diabetes Mellitus, and Bipolar Disorder. The resident's medication regimen included several prescriptions such as Gabapentin, Synjardy, and Breo Ellipta, among others. During the medication pass, an LPN administered only three medications initially and failed to verify the resident's identity through standard procedures such as checking the wristband or confirming with another staff member. The resident requested additional medications, including an inhaler and Percocet, which the LPN then administered without performing hand hygiene. Furthermore, the LPN did not instruct the resident to rinse his mouth after using the Breo Ellipta inhaler, contrary to the instructions on the medication packaging. Interviews conducted with the LPN and the resident confirmed that no other medications were administered before or after the observed medication pass. The LPN had inaccurately documented the administration of other scheduled medications, which were not given. The Director of Nursing acknowledged the LPN's error, attributing it to her being a new nurse who became nervous during the medication pass.
Improper Medication Disposal by New LPN
Penalty
Summary
The facility failed to ensure that all disposed medications were stored securely, as observed during a medication administration for a resident. During the observation, a Licensed Practical Nurse (LPN), who had been working at the facility for one month and was a new graduate, accidentally spilled a pill from the medication cup and placed it into an uncovered trash bin located on the side of the medication cart. In an interview conducted shortly after the incident, the LPN acknowledged that the medication should have been disposed of in the drug buster located in the bottom drawer of her cart, indicating a failure to follow proper drug disposal procedures.
Repeated Deficiencies in QAPI/QAA and Facility Management
Penalty
Summary
The facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to effectively implement plans of action to correct identified quality deficiencies. This was evidenced by repeated deficient practices in maintaining a safe, clean, comfortable, and homelike environment (F584), managing tube feeding (F693), properly disposing of garbage and refuse (F814), and conducting QAPI/QAA improvement activities (F867). These deficiencies were previously cited during the recertification and relicensure survey with an exit date of 06/18/23 and were observed again during the current survey. The repeated deficiencies have the potential to affect all 116 residents residing in the facility at the time of the survey.
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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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