Concordia Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Petersburg, Florida.
- Location
- 321 13th Ave N, Saint Petersburg, Florida 33701
- CMS Provider Number
- 105714
- Inspections on file
- 18
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 6 (3 serious)
Citation history
Health deficiencies cited at Concordia Manor during CMS and state inspections, most recent first.
A resident who was dependent on staff for all care and required two-person assistance for bed mobility fell from bed when only one staff member was present and unaware of the care plan requirements. The resident's pain was not promptly assessed or managed, there were delays in obtaining diagnostic imaging and physician evaluation, and documentation was incomplete. Communication failures and lack of staff training contributed to ongoing pain and distress for the resident following the incident.
A resident who was bedbound and dependent on two-person assistance for care fell from bed while only one staff member was present, leading to a hip fracture and ongoing pain. The staff member was unfamiliar with the resident’s needs, and pain management was inconsistent. There was a lack of timely physician assessment, incomplete documentation, and delayed communication with the family, resulting in a worsened condition for the resident.
Two residents experienced ongoing uncontrolled pain and psychosocial harm after a fall due to the facility's failure to provide timely assessment, notify the physician, complete ordered diagnostics, and consistently administer and document pain management. One resident, who was severely contracted and dependent for all ADLs, was not assisted by two staff as required, leading to a fall and hip fracture. Staff were not adequately trained or informed of care plan changes, and pain care plans were not updated to reflect the resident's increased pain.
A resident with multiple comorbidities and bilateral above-knee amputations, who is dependent on staff for bathing, was not provided showers as preferred due to the facility's lack of bariatric shower equipment. Staff were aware of the resident's wishes but only provided bed baths, and there was no policy or procedure in place to address the need for bariatric accommodations.
The facility did not provide evidence of a current annual diesel fuel quality test for its generator and failed to submit its comprehensive emergency management plan (CEMP) for annual review and approval, as confirmed during record reviews and interviews with the Director of Maintenance.
The facility did not ensure that staff were trained and available on all shifts to manually transfer power to the generator during a power outage, as required by state regulations. The Director of Maintenance was unaware that staff lacked this training, resulting in a deficiency related to emergency environmental control procedures.
A resident in a LTC facility, who was non-verbal and dependent on staff for all care, fell from bed and sustained a head injury due to inadequate staffing. The facility was understaffed, and only one CNA was available to assist the resident, despite the care plan requiring two-person assistance. The incident was not promptly reported or investigated, and the care plan was not active at the time, leaving staff unaware of the resident's needs.
A resident in a LTC facility, who was non-verbal and dependent on staff for all ADLs, fell from bed and sustained a head injury due to insufficient staffing. The CNA, aware of the need for two-person assistance, attempted to care for the resident alone due to understaffing. The facility's administration was slow to respond, and the care plan was not active at the time, contributing to the incident.
The facility failed to timely report allegations of neglect and mistreatment for two residents. One resident's injury was not investigated promptly due to staff being on leave and delayed corporate notification. Another resident reported rough treatment by staff, but the NHA delayed reporting and did not conduct thorough interviews. The facility's process of waiting for corporate approval affected the timeliness of reporting and investigations.
The facility failed to investigate allegations of neglect and mistreatment for two residents. One resident fell from a bed due to inadequate assistance, and the investigation was delayed. Another resident reported rough treatment by staff, but the investigation was incomplete. The facility did not follow its policies, resulting in unresolved allegations.
A facility failed to conduct and document weekly skin assessments for a resident as required by their policy. Over a four-month period, only four skin checks were completed, despite the resident having conditions such as wasting and atrophy. The DON acknowledged the oversight, stating that the assessments should have been documented weekly.
A resident in a LTC facility was left calling for help for 30 minutes without receiving incontinence care, despite multiple staff members passing by. The resident's care plan required assistance with toileting and personal hygiene, but staff failed to respond to her needs, leading to a deficiency in her quality of life.
The facility failed to repair a non-functional air conditioning unit for over a month, despite approval for repairs, and relied on a portable unit in the meantime. Additionally, two resident rooms were not maintained in a safe and sanitary manner, with observed cracking, peeling, and dislodged ceiling material. The NHA confirmed the A/C unit had not been fixed but did not address the room conditions.
The facility did not meet the minimum staffing requirements for nursing and CNAs on five out of twenty-eight days. Nursing care fell below the required 1.0 hours on two days, and CNA care was below the 2.0 hours requirement on three days. The BOM and NHA confirmed the staffing numbers, and the facility's policy holds the administrator and DON responsible for ensuring sufficient staff.
The facility failed to repair a non-functional air conditioning unit for over a month, relying on a portable unit instead. Despite obtaining quotes and approval for repairs, no timeline was provided. Additionally, two resident rooms had issues with cracking and dislodged ceiling material, affecting the safety and sanitation of the environment.
A resident in an LTC facility was left calling for help for approximately 30 minutes without response from staff, despite multiple staff members passing by. The resident needed assistance with toileting and expressed a desire to be clean. The DON confirmed the importance of timely care, and the resident's care plan highlighted her dependency on staff for toileting and a behavior of calling out for help.
The facility failed to provide a safe, clean, comfortable, and homelike environment in six resident rooms and the medication room. Observations included holes in walls, exposed wires, cracked baseboards, and dusty surfaces. The DON and Maintenance Director acknowledged the issues but did not prioritize them due to other safety concerns. The facility's policy on maintaining a safe environment was not effectively implemented.
The facility failed to ensure kitchen equipment was being utilized in safe operating conditions. Observations revealed standing water and constant drips in two refrigerators, and a sink with a makeshift plastic cup to redirect water. Staff interviews confirmed these issues had been ongoing for several months, and maintenance attempts had been ineffective. The Maintenance Director was only present a couple of days a week, and there was a gap in work orders being submitted.
The facility failed to notify a resident and their representative of the bed hold prior to and upon transfer to the hospital. The Bed Hold and In-House Transfer Policy form was incomplete, and interviews confirmed that the facility's practice of notifying the resident or representative at the time of transfer was not followed.
The facility failed to ensure accurate Level I PASRR screenings for seven residents, resulting in discrepancies and incomplete documentation of their mental health diagnoses. The DON acknowledged the inaccuracies and the need for a plan to review and update all PASRRs.
Failure to Ensure Safe Bed Mobility and Timely Medical Response Resulting in Resident Harm
Penalty
Summary
The facility failed to protect residents from neglect by not ensuring safety during bed mobility in accordance with assessed and care planned needs. One resident, who was severely cognitively and physically impaired, dependent on staff for all activities of daily living, and required two-person assistance for bed mobility, sustained a fall from bed during care when only one staff member was present. The staff member was unaware of the resident's two-person assist requirement and did not request help, citing that other staff were busy and that she had not received training specific to the resident. The resident fell while the staff member was preparing to provide care, and the incident was not properly assessed or documented by nursing staff at the time. Following the fall, the resident experienced acute pain that was not promptly addressed. There was a delay in both the assessment and management of the resident's pain, as well as in obtaining necessary diagnostic imaging. The resident was not seen by a physician in a timely manner, and an ordered X-ray was not completed as expected. The resident was eventually transferred to the hospital, where a hip fracture was diagnosed. Upon return to the facility, there were further delays in pain management due to issues with medication orders and communication, resulting in the resident experiencing ongoing pain and distress. Interviews and record reviews revealed inconsistencies and confusion among staff regarding the resident's care plan and required level of assistance. Documentation was lacking for post-fall assessments, pain management, and follow-up care. The resident's family was not promptly notified of the fall, and there were issues with communication and continuity of care between facility staff and the resident's primary care provider. The failure to follow the care plan, provide adequate staffing and training, and ensure timely medical intervention resulted in a worsened condition for the resident and constituted neglect.
Failure to Provide Adequate Staffing and Supervision During Bed Mobility Results in Resident Injury
Penalty
Summary
The facility failed to provide the required number of staff to ensure resident safety during bed mobility, as outlined in the care plans for multiple residents. One resident, who was severely contracted, bedbound, and dependent on two-person assistance for all activities of daily living, experienced a fall from bed while only one staff member was present during care. The staff member assigned was unfamiliar with the resident’s care needs, had not received specific training, and did not request additional assistance due to staffing shortages and being unaware of the resident’s two-person assist requirement. The resident fell to the floor during care, and staff subsequently assisted the resident back to bed without a documented assessment or vital signs being taken at the time of the incident. Following the fall, the resident experienced ongoing and severe pain, which was not consistently addressed or documented by nursing staff. Pain medication was not always administered as ordered, and there were delays in both pain assessment and intervention. The resident’s family was not promptly notified of the fall, and there were issues with communication regarding the resident’s hospital admission, including the use of the wrong name. The resident was eventually transferred to the hospital after continued complaints of pain and was diagnosed with a right hip fracture. The hospital determined the resident was not a candidate for surgery due to contractures and comorbidities, resulting in ongoing physical and psychosocial pain. The facility also failed to ensure timely physician assessment and follow-up after the fall. There was no evidence that the resident was seen by a physician throughout the month following the incident, and an ordered X-ray was not completed in a timely manner. Documentation of post-fall assessments, pain management, and care plan interventions was lacking. Interviews with staff and the resident’s family confirmed that the resident’s pain was not adequately managed, and the care plan interventions were not consistently implemented. These failures resulted in a worsened condition for the resident and created a situation of Immediate Jeopardy.
Failure to Provide Timely and Effective Pain Management Post-Fall
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents following a fall, resulting in ongoing uncontrolled pain and psychosocial harm. One resident, who was severely contracted and dependent on staff for all activities of daily living, sustained a femur fracture after falling from bed during care. Despite clear care plan instructions requiring two-person assistance for bed mobility and transfers, only one staff member was present at the time of the fall. The staff member involved was not adequately trained on the resident's care needs and did not request assistance, citing that other staff were busy. After the fall, the resident was assisted back to bed without a thorough assessment or documentation of vital signs and skin checks, and the family was not promptly notified of the incident. Following the fall, the resident experienced persistent and severe pain that was not effectively managed. There were delays in both the assessment and notification of the physician regarding the resident's pain, and an ordered X-ray was not completed in a timely manner. The resident was eventually transferred to the hospital, where a hip fracture was diagnosed, but she was deemed a poor surgical candidate due to her contractures and comorbidities. Upon return to the facility, there were further delays in administering prescribed pain medication due to prescription issues, and documentation of pain management was inconsistent. Staff interviews confirmed that the resident continued to experience significant pain, especially during care, and that pain assessments and care plan updates were lacking. The facility's documentation and communication failures extended to the care planning process, as the resident's pain care plan was not updated to reflect her increased pain and new interventions were not promptly implemented. Staff were not consistently aware of or following the most current care plan interventions, and there was a lack of coordination between therapy and nursing regarding pain management strategies. The cumulative effect of these failures resulted in ongoing physical pain and psychosocial distress for the resident, and the situation was determined to constitute Immediate Jeopardy.
Failure to Provide Shower Accommodations for Bariatric Resident
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's preference for showers. The resident, who is cognitively intact and dependent on staff for bathing due to multiple comorbidities including multiple sclerosis, morbid obesity, bilateral above-knee amputations, and muscle weakness, repeatedly expressed her desire for regular showers rather than bed baths. Despite her care plan and Kardex specifying scheduled showers twice weekly with assistance, she had not received a shower since admission and was only provided bed baths. Staff interviews confirmed awareness of the resident's preference but cited the lack of appropriate bariatric shower equipment as the reason for not providing showers. Observations of the shower room confirmed the absence of bariatric shower chairs, and staff acknowledged that all available shower chairs were standard size and unsuitable for bariatric residents. The physical therapy assistant indicated she had not been consulted about the need for bariatric equipment, and the regional consultant and nurse consultant were unaware of any policy or procedure for accommodating such needs. Documentation showed the resident had only received bed baths, and there was no evidence of efforts to obtain suitable equipment to meet her preferences.
Failure to Maintain Generator Fuel Quality Testing and Annual Emergency Management Plan Submission
Penalty
Summary
The facility failed to maintain the required annual diesel fuel quality test for its generator, as mandated by NFPA 101, NFPA 99, and NFPA 110. During a record review of the Essential Electrical System (EES) with the Director of Maintenance (DOM), it was found that there was no evidence of a current annual diesel fuel quality test. The DOM confirmed during the interview that the documentation for this test was not available. Additionally, the facility did not submit its comprehensive emergency management plan (CEMP) for annual review and approval as required by Florida Administrative Code 408.821. During a record review with the DOM, it was revealed that the facility could not provide evidence of the CEMP's submission to the county for the required annual review. The CEMP had expired, and the DOM stated that the facility currently has an interim Administrator who has only been at the facility for a few months. No information was provided in the report regarding specific residents or their medical conditions in relation to these deficiencies. The findings were based on documentation review and interviews with facility staff, specifically the DOM.
Plan Of Correction
Fuel sample was collected on by vendor for testing. No residents were affected by deficient practice. Education will be completed with the NHA/designee by regional plant operations on fuel inspection requirements. Audits will be completed by the NHA/designee who will audit the electronic work order system for equipment inspection compliance weekly for four weeks then monthly for two months. Results of the audit will be reported to the QAA&C Committee for comments and recommendations monthly for three months. CEMP was submitted to the county agency for review. No residents were affected by deficient practice. Education was completed with the NHA/designee by the regional director of plant operations regarding the annual requirement for CEMP approval. Audits will be completed by the NHA/designee on the CEMP approval compliance weekly for four weeks then monthly for two months. Results of the audit will be reported to the QAA&C Committee for comments and recommendations monthly for three months.
Failure to Ensure Trained Staff for Manual Power Transfer During Outages
Penalty
Summary
The facility failed to provide a detailed emergency power plan in accordance with the Florida Administrative Code (FAC) requirements. During a record review conducted between 9:15 AM and 10:15 AM with the Director of Maintenance (DOM), it was found that the facility could not provide evidence that an on-site and trained individual was available during all shifts to manually transfer power from the public utility to the generator using the generator's manual transfer switch in the event of a power outage. In an interview conducted concurrently with the record review, the DOM stated that he had only been responsible for the facility for a few months and was not aware that staff were not trained for the task of manually transferring power. This lack of awareness and training among staff directly contributed to the facility's inability to meet the regulatory requirement for emergency environmental control. The deficiency was cited under FAC 59A-4.1265(6)(a), which mandates that nursing homes develop and implement written policies and procedures to ensure effective and immediate activation, operation, and maintenance of the alternate power source. The facility's failure to ensure that staff were trained and available to perform the manual transfer of power during all shifts led to noncompliance with this regulation.
Plan Of Correction
Education was completed with facility staff regarding the manual transfer of power during a power outage through the generator manual transfer switch. New employees will be educated on this process as part of the orientation process. Education will be completed with the NHA/designee by the regional plant consultant on manual transfer of generator task education requirement. An audit will be completed by the NHA/designee and will include all new employee files on transfer of power education completion. The audit will be conducted weekly for 4 weeks, then weekly for 2 weeks, and monthly for 2 weeks. Results of the audit will be reported to the QAA&C Committee for comments and recommendations monthly for three months.
Inadequate Staffing Leads to Resident Injury
Penalty
Summary
The deficiency involved a failure to provide adequate staffing to ensure the safety of a resident during bed mobility, which was consistent with the assessed and care-planned needs. The resident, who was non-verbal and dependent on staff for all care, required the assistance of two staff members for bed mobility. However, on the day of the incident, the facility was understaffed due to call-offs, and only one CNA was available to assist the resident. This resulted in the resident falling from the bed and sustaining a head injury, which required a transfer to a higher level of care. The CNA involved in the incident admitted to attempting to care for the resident alone, despite knowing that the resident required two-person assistance. The CNA stated that she tried to lower the bed and call for help when the resident began to fall, but was unable to prevent the fall. The facility's staffing issues were highlighted by multiple staff members, who reported that understaffing was a common problem and that the administration often allowed shifts to continue without adequate replacements. The facility's policies and procedures for care planning and staffing were not effectively implemented, as evidenced by the unresolved care plan issues and the lack of timely reporting and investigation of the incident. The care plan for the resident was not active at the time of the incident, and staff were not aware of the resident's transfer status. Additionally, the facility's administration failed to promptly report the incident to the appropriate authorities, and the investigation was delayed due to the absence of key personnel.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any of its rights to contest any of these allegations or any allegation or action. #1's care plan was reviewed and updated as indicated. Nursing Home Administrator (NHA) and/or Director of Nursing (DON) conducted an audit of resident grievances and/or incidents to ensure that there were no concerns identified related to insufficient staffing levels. No new concerns were identified. Element #2. A review of facility staffing levels was completed to ensure adequate staffing levels in place to meet the needs of the residents. No additional opportunities identified. An evaluation of current residents was conducted by the Director of Nursing (DON) and/or designee to ensure that no additional residents were by the alleged deficient practice. No other opportunities were identified. Element #3. Current licensed nursing staff were in-serviced on the facility's Policy and Procedure and Neglect, and Policy as it relates to providing necessary assistance with activities of daily living, prevention, and potential for resident harm. Nursing Home Administrator (NHA) and Director of Nursing (DON) were in-serviced by Regional Nurse Consultant and/or Regional Director of Operations Consultant regarding the requirement that a daily staffing meeting/review is completed to ensure that daily minimum staffing levels are met and maintained. A plan was developed and implemented to enhance the hiring of registered, licensed, and certified nursing staff as required to assist with maintaining daily minimum staffing levels. Recruitment efforts continue. Element #4. The Director of Nursing (DON) and/or designee will audit staffing levels three times a week for the next 60 days to ensure that staffing levels are appropriate to meet the needs of the residents. Findings will be brought by the Nursing Home Administrator (NHA) and/or designee to the Quality Assessment and Assurance Committee monthly meeting for three months for further comments and/or recommendations. Element #5. Facility's Allegation of Compliance Date is , 20225.
Neglect Due to Insufficient Staffing Leads to Resident Injury
Penalty
Summary
The deficiency involved a resident who was neglected due to insufficient staffing during a bed mobility task. The resident, who was non-verbal and dependent on staff for all activities of daily living, required the assistance of two staff members for safe bed mobility. However, on the day of the incident, the facility was understaffed, with only one nurse and two CNAs available for the entire building. As a result, a CNA attempted to care for the resident alone, which led to the resident falling from the bed and sustaining a head injury that required hospital transfer. The CNA involved admitted to not asking for help despite knowing the resident required two-person assistance. The CNA attempted to manage the situation by lowering the bed and calling for help, but the resident still fell and was injured. The CNA acknowledged the mistake and attributed it to the lack of available staff, as the facility did not replace staff who called off that day. The incident highlighted a recurring issue of understaffing, which was acknowledged by other staff members who reported similar experiences of being unable to provide adequate care due to insufficient staffing levels. The facility's administration was slow to respond to the incident, with the Director of Nursing and Nursing Home Administrator only becoming aware of the situation days later. The care plan for the resident was not active at the time of the incident, which contributed to the confusion about the required level of assistance. The facility's policies on care planning and injury prevention were not effectively implemented, as evidenced by the unresolved care plan and the lack of timely reporting and investigation of the incident.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any of its rights to contest any of these allegations or any allegation or action. F-600 Free From and Neglect Element #1: Resident #1 was assessed to ensure no further injuries, and that was at a level that was acceptable to the resident. No additional findings noted upon assessment and level at acceptable level for resident. Resident #1's care plan was reviewed and updated as indicated. Nursing Home Administrator (NHA) and/or Director of Nursing (DON) conducted an audit of resident grievances and/or incidents to ensure that there were no concerns identified related to insufficient staffing levels. No new concerns were identified. Element #2: A review of facility staffing levels was completed to ensure adequate staffing levels in place to meet the needs of the residents. No additional opportunities identified. An evaluation of current residents was conducted by the Director of Nursing (DON) and/or designee to ensure that no additional residents were affected by the alleged deficient practice. No other opportunities were identified. Element #3: Current licensed nursing staff were in-serviced on the facility's Policy and Procedure and Neglect, and Policy as it relates to providing necessary assistance with activities of daily living, prevention, and potential for resident harm. Nursing Home Administrator (NHA) and Director of Nursing (DON) were in-serviced by Regional Nurse Consultant and/or Regional Director of Operations Consultant regarding the requirement that a daily staffing meeting/review is completed to ensure that daily minimum staffing levels are met and maintained. A plan was developed and implemented to enhance the hiring of registered, licensed, and certified nursing staff as required to assist with maintaining daily minimum staffing levels. Recruitment efforts continue. Element #4: The Director of Nursing (DON) and/or designee will audit staffing levels three times a week for the next 60 days to ensure that staffing levels are appropriate to meet the needs of the residents. Findings will be brought by the Nursing Home Administrator (NHA) and/or designee to the Quality Assessment and Assurance Committee monthly meeting for three months for further comments and/or recommendations. Element #5: Facility's Allegation of Compliance Date is , 20225.
Delayed Reporting of Allegations of Neglect and Mistreatment
Penalty
Summary
The facility failed to report allegations of neglect and mistreatment in a timely manner for two residents. For the first resident, a hospital visit summary indicated an injury, but the Nursing Home Administrator (NHA) did not initiate an investigation until several days later. The NHA was not informed of the incident over the weekend, and the Director of Nursing (DON) and Director of Rehab were on leave. The NHA only became aware of the incident after being notified by corporate, which delayed the reporting to the Agency for Health Care Administration (AHCA). For the second resident, there were two separate incidents involving allegations of rough treatment by staff. The resident reported a staff member being rough and loud, but the NHA did not report the allegation until a day later. The NHA admitted to not asking detailed questions or interviewing other staff members. In another incident, a family member reported to the state agency that a staff member physically shook and yelled at the resident. The state agency investigated but did not substantiate the claim. The NHA did not obtain statements from the involved staff or follow up on the resident's complaints. The NHA acknowledged that the facility's process of waiting for corporate approval before reporting incidents affected the timeliness of their reporting and investigations. The facility's failure to promptly report and investigate these allegations resulted in deficiencies in meeting the regulatory requirements for reporting alleged violations of neglect and mistreatment.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any of its rights to contest any of these allegations or any allegation or action. F-609, Reporting Alleged Violations Element #1. Resident's #1 and #3 were assessed to ensure there were no negative outcome from the alleged deficient practice. No negative findings identified. Element #2. The Nursing Home Administrator (NHA) and/or designee conducted an audit to identify any other allegations that were reported late within the past 30 days. Residents with previous reports were reassessed for ongoing safety and care concerns. No additional concerns identified. Element #3. Current facility staff will be in-serviced by the Nursing Home Administrator (NHA) and/or designee on timeliness of reporting allegations of neglect, and as well as the timeframes in which to report allegations to ensure they understand when and how to submit allegations in a timely manner. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were in-serviced by the Regional Vice President and/or Regional Nurse Consultant on timeliness of reporting allegations of neglect, and as well as the timeframes in which to report allegations to ensure they understand when and how to submit allegations in a timely manner. Element #4. The Nursing Home Administrator (NHA) and/or designee will audit new reportables once a week for the next 60 days to ensure timeliness of reporting. Findings will be brought by the Nursing Home Administrator (NHA) and/or designee to the Quality Assessment and Assurance Committee monthly meeting for three months for further comments and/or recommendations. Element #5. Facility's Allegation of Compliance Date is .
Failure to Investigate Allegations of Neglect and Mistreatment
Penalty
Summary
The facility failed to thoroughly and timely investigate allegations of neglect and mistreatment for two residents. For the first resident, a Certified Nursing Assistant (CNA) was involved in an incident where the resident fell from the bed. The CNA admitted to not asking for help despite knowing the resident required two-person assistance. The Nursing Home Administrator (NHA) did not initiate an investigation until days later, after being prompted by corporate, and failed to report the incident to the Agency for Health Care Administration (AHCA) in a timely manner. The NHA also did not interview other staff or residents at the time of the incident. For the second resident, there were multiple allegations of rough treatment by staff. The resident reported a CNA for being rough and loud, but the NHA did not thoroughly investigate the claim, failing to ask for detailed statements or interview other staff. Another incident involved a family member reporting to the Department of Children and Families (DCF) that an occupational therapist was physically shaking and yelling at the resident. The NHA did not obtain a statement from the accused staff member or conduct a comprehensive investigation. The facility's policy on prevention and investigation of abuse, neglect, and mistreatment was not followed. The NHA admitted to not obtaining necessary statements or educating staff following these incidents. The facility's failure to adhere to its own policies and procedures resulted in delayed and incomplete investigations, leaving allegations unresolved and unaddressed.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any of its rights to contest any of these allegations or any allegation or action. F-610, Investigate/Prevent/Correct Alleged Violations Element #1. Resident #1 was assessed to ensure no further injuries, and that was at a level that was acceptable to the resident. Resident #1's care plan was updated as indicated. Resident #3 was assessed and her grievance regarding care and customer service was reviewed. The Nursing Home Administrator (NHA) and/or designee reinterviewed staff and residents and collected witness statements. The Nursing Home Administrator (NHA) and/or designee contacted the appropriate reporting agencies, the resident's primary care physician, and resident's families/responsible parties. Element #2. The Nursing Home Administrator (NHA) and/or designee conducted an audit to identify any other grievances pending completion or incomplete investigations occurring within the past 30 days. Opportunities that were identified during the audit were corrected as indicated. An evaluation of current residents was conducted by the Director of Nursing (DON) and/or designee to ensure that no residents were by alleged deficient practices. No opportunities were identified. Element #3. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were in-serviced by the Regional Vice President and/or the Regional Nurse Consultant on the Reportable Investigation, and the timeliness of reporting to state authorities to ensure they understand the process of conducting a complete investigation. Element #4. The Nursing Home Administrator and/or designee will audit new grievances and reportables once a week for the next 60 days for accurate and thorough investigations. Findings will be brought by the Nursing Home Administrator (NHA) and/or designee to the Quality Assessment and Assurance Committee monthly meeting for three months for further comments and/or recommendations. Element #5. Facility's Allegation of Compliance Date is
Failure to Conduct Weekly Skin Assessments
Penalty
Summary
The facility failed to maintain medical records in accordance with professional standards and policy for weekly skin evaluations and assessments for one resident. The facility's policy, titled 'Prevention and Treatment Overview,' mandates weekly skin integrity reviews to proactively identify changes in skin condition. However, a review of the resident's records revealed that only four skin checks were completed over a four-month period, contrary to the policy requirement of weekly documentation. The Director of Nursing (DON) acknowledged the oversight, stating that the skin checks should have been documented weekly but were not. The resident involved was admitted to the facility in 2013 and readmitted with diagnoses including wasting and atrophy, unspecified occlusion, and aphasia. During the period in question, the resident's records showed a knot on the forehead, which was noted in the limited skin assessments conducted. The DON confirmed that the facility missed the required weekly assessments and documentation, which should have been performed as per the facility's policy.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any of its rights to contest any of these allegations or any allegation or action. F-842, Resident Records-Identifiable Information Element #1. Skin check for Resident #1 was completed and documented in the electronic medical record. No new areas of concern were identified. Element #2. Director of Nursing (DON) and/or designee conducted a full-house skin sweep on current residents to identify any new areas of skin. No new areas of concern were identified. Element #3. The Director of Nursing (DON) and/or designee will educate current licensed clinical staff on performing weekly skin checks on active residents and documenting findings in the electronic medical record timely and efficiently. Physicians and families will be notified of any newly identified skin and any new orders will be transcribed into the electronic medical record as indicated. Element #4. Director of Nursing (DON) and/or designee will audit the weekly skin checks for active residents in the electronic medical record every week for eight (8) weeks to ensure that the weekly skin checks are being performed timely. Results of the audits will be brought by the Nursing Home Administrator (NHA) or Director of Nursing (DON) and discussed at monthly Quality Assurance Performance Improvement meetings for review and recommendation for three months. Element #5. Facility's Allegation of Compliance Date is , 20205.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, leading to a deficiency in promoting the resident's quality of life. During a facility tour, the resident was observed calling for help for approximately 30 minutes without receiving assistance. The resident expressed a need for toileting and incontinence care, stating she had soiled herself and wanted to be clean. Despite her continuous calls for help, multiple staff members, including LPNs, CNAs, and other facility personnel, walked past her room without responding to her needs. The resident's care plan indicated she was incontinent of bladder and bowel and required assistance with toileting and personal hygiene. The care plan aimed to establish a resident-specific toileting program to support continence, reduce infection risk, and improve self-esteem. Additionally, the resident had a behavior problem of continuously calling out for help, with interventions to anticipate and meet her needs. However, during the observed period, staff failed to enter the resident's room to address her calls for help, despite the care plan's directives. Interviews with facility staff, including the DON, confirmed the resident's need for timely care, especially given her condition, which included a wound on her sacrum. The DON acknowledged that staff should have responded to the resident's calls for help, regardless of their position within the facility. The report highlights a lack of adherence to the resident's care plan and a failure to provide necessary incontinence care, resulting in a deficiency in the resident's quality of life.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any rights to contest any of these allegations or any allegation or action. F-675 Quality of Life Element #1. Resident #2 was provided with care on in response to her requests, and no adverse outcomes were noted. Care plans for Resident #2 were reviewed and deemed appropriate. Element #2. Director of Nursing (DON) and/or Designee conducted an interview audit to all current residents on to determine if their verbalizations/requests for care were responded to and addressed in a timely manner. No residents were identified. Element #3. Policy regarding Customer Service was reviewed by the Interdisciplinary Team (IDT) and deemed appropriate. Staff A (Licensed Practical Nurse/LPN), Staff B (Certified Nursing Assistant CNA), Maintenance Director, Activities Director, and Staff D (Licensed Practical Nurse/LPN) were individually in-serviced by Director Of Nursing (DON) regarding the expectation that staff respond to and address resident verbalizations/requests to ensure that they are addressed in a timely manner. Element #4. Director of Nursing (DON) and/or Designee will conduct random interview audits with interviewable residents three (3) times a week for four (4) weeks, then two (2) times weekly times eight (8) weeks and/or until substantial compliance is achieved to ensure that resident verbalizations/requests for care are responded to and addressed in a timely manner. Grievances will be completed on behalf of those residents who are verbalizing concerns. Completed audits will be brought to the daily stand-up meetings and reviewed by the Interdisciplinary Team (IDT). Results of the audits will be brought by the Director of Nursing (DON) and discussed at monthly Quality Assurance Performance Improvement Meetings for review and recommendation for three (3) months. Element #6: Facility's Allegation of Compliance Date is
Facility Fails to Repair A/C Unit and Maintain Resident Rooms
Penalty
Summary
The facility failed to ensure timely repairs for one of three air conditioning units, which had been non-functional for approximately one month. The Director of Maintenance (DOM) identified the malfunction on 01/28/2025, and a proposal for repairs was submitted, but as of 03/07/2025, the repairs had not been completed despite approval of the purchase requisition on 02/12/2025. The facility relied on a portable unit in the interim, but no further information was provided regarding the timeline for the repair of the air conditioning unit. Additionally, the facility did not maintain resident rooms in a safe and sanitary manner, as evidenced by observations of cracking, peeling, and dislodged ceiling material with discoloration in two resident rooms. Room 104, which was unoccupied, had three areas of dislodged paint, each approximately 2 feet by 3 feet. Room 105, which housed four residents, had similar issues with cracks and discolored paint material approximately 2 feet by 2 feet. The Nursing Home Administrator (NHA) confirmed the air conditioning unit had not been fixed but did not comment on the condition of the resident rooms.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any rights to contest any of these allegations or any allegation or action. F-0908 Essential Equipment, Safe Operating Condition Element #1. The facility's air conditioning unit was repaired on, Ceiling in resident are scheduled for repair on. Element #2. The facility's remaining air conditioning units were inspected for proper functioning on and no concerns were identified. Resident room ceilings were inspected for cracked and/or peeling paint on No areas of noncompliance were identified. Element #3. Nursing Home Administrator (NHA) and/or Designee in-serviced Concierge personnel and facility staff regarding the identification and reporting of any areas of disrepair or noncompliance of the physical environment in resident rooms. Nursing Home Administrator (NHA) in-serviced Maintenance Director regarding the Physical Environment Policy. Regional Director of Operations Consultant in-serviced the Nursing Home Administrator (NHA) regarding management of product or equipment requisitions. Element #4. Nursing Home Administrator (NHA) will randomly audit resident room ceilings and air conditioning units five (5) times weekly times eight (8) weeks to ensure that ceilings do not have cracked/peeling paint and that air conditioning units are properly functioning. Completed audits will be brought to the stand up meetings and reviewed by the Interdisciplinary Team (IDT). Results of the audits will be brought by the Nursing Home Administrator (NHA) or Director of Nursing (DON) and discussed at monthly Quality Assurance Performance Improvement meetings for review and recommendation. Element #5: Facility's Allegation of Compliance Date is.
Failure to Meet Minimum Staffing Requirements
Penalty
Summary
The facility failed to meet the minimum staffing requirements for nursing and certified nursing assistants (CNAs) on five out of twenty-eight days reviewed. Specifically, the facility did not meet the nursing minimum daily requirement of 1.0 hours of direct care on two days and failed to meet the CNA minimum daily requirement of 2.0 hours of direct care on three days. The daily averages for nursing and CNA care on these days were below the required thresholds, with nursing care averaging as low as 0.8787 hours and CNA care averaging as low as 1.8823 hours per resident per day. Interviews with the Business Office Manager (BOM) and the Nursing Home Administrator (NHA) confirmed the accuracy of the staffing numbers provided on the Long Term Care (LTC) sheets. The BOM stated that the Director of Nursing (DON) is responsible for the staffing schedule, and she inputs the numbers into the payroll system. The NHA acknowledged awareness of the days when staffing numbers did not meet the minimum requirements. The facility's policy and procedure for staffing indicate that the administrator and DON are responsible for ensuring sufficient nursing staff to meet federal and state law requirements, with staffing plans re-evaluated on an ongoing basis.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any rights to contest any of these allegations or any allegation or action. N-063, Minimum Nursing Staff Element #1. A review of the State Minimum Nursing Staff for four (4) weeks (28 days) was conducted on __ of __, and the facility was identified to have failed to achieve minimum staffing requirements for Nursing on __ and __ and for Certified Nursing Assistants (CNA) on __ and __. The facility ensured that appropriate minimum staffing levels were achieved on the dates between those and from __ forward. Element #2. Nursing Home Administrator (NHA) and/or Director of Nursing (DON) conducted an audit on __ of __ resident grievances and/or incidents to ensure that there were no concerns identified which correlated with the day/dates when the facility failed to ensure that minimum staffing requirements were met. No concerns were identified. Element #3. Policy regarding State Minimum Staffing Requirements were reviewed by the Interdisciplinary Team (IDT) and deemed appropriate. Nursing Home Administrator (NHA) and Director of Nursing (DON) were in-serviced by Regional Nurse Consultant and/or Regional Director of Operations Consultant regarding the requirement that a daily staffing meeting/review is completed to ensure that daily minimum staffing levels are met and maintained. A plan is developed and implemented to enhance the hiring of registered and licensed, and certified nursing staff as required to assist with maintaining daily minimum staffing levels. Nurse and CNA's were called for interviews. Waiting for orientation are four (5) CNA's and one (1) Nurse. Other interviews are scheduled and pending. Element #5: Facility's Allegation of Compliance Date is __.
Deficiency in HVAC Maintenance and Room Conditions
Penalty
Summary
The facility failed to ensure timely repairs for one of three air conditioning units, which had been non-functional for about a month. The Director of Maintenance (DOM) acknowledged that the main board of the unit was not working and that a portable unit was being used as a temporary solution. Despite obtaining quotes and submitting them to the corporate office, the repairs had not been approved or completed at the time of the survey. The maintenance log showed a pending service request for the rooftop unit, which had been unresolved for 43 days. Additionally, a purchase requisition for the repair was approved, but no timeline for the repair was provided. The facility also failed to maintain resident rooms in a safe and sanitary manner. Observations revealed that two resident rooms had issues with cracking, peeling, and dislodged ceiling material with discoloration. One room had three areas of concern, each approximately 2 by 3 inches, while another room had cracks with dislodged and discolored painted material approximately 2 by 2 inches. Four residents were residing in the affected room at the time of the survey. The Nursing Home Administrator confirmed the approval of the purchase requisition but did not provide comments on the maintenance and repairs policy.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any rights to contest any of these allegations or any allegation or action. N-112, Physical Environment and Physical Maintenance Element #1. The facility's air conditioning unit was repaired on . Ceiling in resident are scheduled for repair on . Element #2. The facility's remaining air conditioning units were inspected for proper functioning on and no concerns were identified. Resident room ceilings were inspected for cracked and/or peeling paint on . No areas of noncompliance were identified. Element #3. Nursing Home Administrator (NHA) or designee in-serviced Concierge personal and staff regarding the identification and reporting of any areas of disrepair or noncompliance of the physical environment in resident rooms. Nursing Home Administrator (NHA) and/or designee in-serviced Maintenance Director regarding the Physical Environment Policy. Regional Director of Operations Consultant in-serviced Nursing Home Administrator (NHA) regarding management of product or equipment requisitions. Element #4. Nursing Home Administrator (NHA) will randomly audit resident room ceilings and air conditioning units five (5) times weekly times eight (8) weeks to ensure that ceilings do not have cracked/peeling paint and that air conditioning units are properly functioning. Completed audits will be brought to the stand up meetings and reviewed by the Interdisciplinary Team (IDT). Results of the audits will be brought by the Nursing Home Administrator (NHA) or Director of Nursing (DON) and discussed at monthly Quality Assurance Performance Improvement meetings for review and recommendation. Element #5: Facility's Allegation of Compliance Date is .
Failure to Respond to Resident's Calls for Help
Penalty
Summary
The facility failed to provide timely care and services to promote the quality of life for a resident, as evidenced by the resident's continuous calls for help that went unanswered for approximately 30 minutes. During a facility tour, the resident was observed calling for assistance with toileting needs, stating she had 'messed' herself. Despite her cries for help being audible from the hallway, multiple staff members, including an LPN, CNAs, the Maintenance Director, and the Activities Director, walked past the resident's room without responding to her calls. Interviews conducted with the Director of Nursing (DON) and the Clinical Reimbursement Director confirmed that the resident did not use the call bell but would call out for help. The DON stated that staff should enter the room to inquire about the resident's needs when they hear a resident calling for help. The resident expressed a desire to be clean, and the DON acknowledged the importance of timely care, confirming that the resident had experienced a bowel movement during the morning observations. A review of the resident's care plan revealed a focus on providing assistance with toileting and personal hygiene to maintain cleanliness and dignity. The care plan also noted the resident's dependency on staff for toilet use and a behavior problem of continuously calling out for help. The facility did not provide a policy related to this issue, and the deficiency was classified as Class III.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any rights to contest any of these allegations or any allegation or action. N-201, Right to Adequate and Appropriate Healthcare Element #1. Resident #2 was provided with care on in response to her requests, and no adverse outcomes were noted. Care Plans for Resident #2 were reviewed and deemed appropriate. Element #2. Director of Nursing (DON) and/or Designee conducted an interview audit with interviewable residents on /205 to determine if their verbalizations/requests were responded to and addressed in a timely manner. No additional residents were identified. Element #3. Staff A (Licensed Practical Nurse/LPN). Staff B (Certified Nursing Assistant/CNA), Maintenance Director, Activities Director, and Staff D (Licensed Practical Nurse/LPN) were individually in-serviced by Director of Nursing (DON) regarding the expectation that staff respond to and address resident verbalizations/requests in a timely manner. Interdisciplinary staff were in-serviced by the Director of Nursing (DON) and/or Nursing Home Administrator (NHA) regarding the expectation that any staff member can/should respond to resident verbalizations/requests to ensure that they are addressed in a timely manner. Element #4. Director of Nursing (DON) and/or Designee will conduct interview audits with interviewable residents three (3) times weekly for four (4) weeks, then two (2) times weekly times eight (8) weeks and/or until substantial compliance is achieved to ensure that resident verbalizations/requests are responded to and addressed in a timely manner. Grievances will be completed on behalf of those residents verbalizing concerns. Completed audits will be brought to the daily stand up meetings and reviewed by the Interdisciplinary Team (IDT). Results of the audits will be brought by the Director of Nursing (DON) and discussed at monthly Quality Assurance Performance Improvement Meetings for review and recommendation. Element #5: Facility's Allegation of Compliance Date is /20525.
Failure to Maintain a Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in six out of eleven resident rooms and the medication room. During a facility tour, multiple deficiencies were observed, including holes in the walls, exposed wires, cracked and peeling baseboards, dusty and grimy surfaces, and moisture-damaged walls. Additionally, the medication room had dust hanging from the air vent, tangled wires, and a clogged sink. The Director of Nursing (DON) and the Maintenance Director acknowledged these issues but indicated that they were either unaware of them or did not prioritize them due to other safety concerns. The Maintenance Director was responsible for two facilities and was only onsite two days a week, which contributed to the lack of timely maintenance and repairs. The facility's policy on maintaining a safe and homelike environment was not effectively implemented, as evidenced by the numerous unaddressed maintenance issues and the inadequate cleaning of air vents and other surfaces. Staff interviews revealed that the housekeeping staff could not properly clean the air vents due to the design of the dusters, and the maintenance staff only addressed issues when they were brought to their attention. The Nursing Home Administrator and other staff members agreed that the observed conditions did not meet the standards for a homelike environment.
Failure to Maintain Kitchen Equipment in Safe Operating Conditions
Penalty
Summary
The facility failed to ensure kitchen equipment was being utilized in safe operating conditions. Observations revealed that a two-door reach-in refrigerator had standing water at the bottom, with a constant water drip from the top, contaminating a container of strawberries. Another one-door reach-in refrigerator also had standing water at the bottom due to a similar water drip. Additionally, a sink had a plastic cup with the bottom cut out to fit over the faucet, which was used to redirect water squirting upwards back into the sink basin. Staff interviews confirmed that these issues had been ongoing for several months, and maintenance attempts had been ineffective. The Maintenance Director (MD) stated that he was only present at the facility a couple of days a week and worked at a sister facility on other days. The MD mentioned that he had replaced a gasket in the two-door refrigerator and had just replaced the sink faucet on the day of the interview. The facility had a gap in work orders being submitted between August 2023 and March 2024, and the MD noted that work orders were initially communicated by word of mouth. The facility's policy required maintaining equipment in proper working order and reporting malfunctions immediately to the Maintenance Department, which was not adhered to in this case.
Failure to Notify Resident and Representative of Bed Hold
Penalty
Summary
The facility failed to ensure that a resident and their representative received a bed hold notification prior to and upon transfer to the hospital. Specifically, Resident #29 was transferred to the hospital on 03/18/2024, but there was no evidence that the resident or their representative was notified of the bed hold. The Admission Record confirmed the resident's health care decision maker, but the Bed Hold and In-House Transfer Policy form for Resident #29 was incomplete, lacking the representative's name and signature to acknowledge receipt of the notification. Interviews with the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) confirmed that the facility's practice is to notify the resident or representative of the bed hold at the time of transfer. However, this procedure was not followed in the case of Resident #29. The facility's policy requires providing written notice of the bed hold upon admission and an additional notice specifying the duration of the bed hold upon transfer, which was not adhered to in this instance.
Inaccurate and Incomplete PASRR Screenings
Penalty
Summary
The facility failed to ensure accurate Level I Pre-Admission Screening & Resident Review (PASRR) for seven residents. Resident #3 and Resident #26 had discrepancies in their PASRRs, as their current diagnoses of Anxiety Disorder and Major Depression were not reflected. The Director of Nursing (DON) acknowledged the discrepancies during an interview, admitting that the PASRRs did not accurately reflect the residents' mental health conditions. Resident #13 and Resident #20 also had inaccuracies in their PASRRs. Resident #13's PASRR did not indicate a diagnosis of schizophrenia, and Resident #20's PASRR did not reflect the need for a Level II PASRR evaluation despite having multiple mental health diagnoses. The DON admitted to not being fully aware of all the indications for Level II PASRR screening. Additionally, Resident #5, Resident #19, and Resident #18 had incomplete PASRRs. Resident #5's PASRR did not check the qualifying diagnosis of major depressive disorder. Resident #19's PASRR missed the diagnoses of anxiety disorder and epilepsy. Resident #18's PASRR did not include Alzheimer's disease, unspecified dementia, psychotic disturbance, and anxiety, and a Level II PASRR was not submitted. The DON and a Regional Nurse Consultant confirmed the incompleteness of these PASRRs and acknowledged the need for a plan to review and update all PASRRs accordingly.
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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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