Coral Bay At Pensacola, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Pensacola, Florida.
- Location
- 600 W Gregory St, Pensacola, Florida 32502
- CMS Provider Number
- 106051
- Inspections on file
- 24
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 32 (9 serious)
Citation history
Health deficiencies cited at Coral Bay At Pensacola, Llc during CMS and state inspections, most recent first.
The facility failed to adequately assess and mitigate the risk posed by a resident with a documented history of aggressive and violent behaviors who was roomed with a cognitively impaired, non-verbal, limited-mobility roommate. Staff had observed the aggressive resident verbally cursing at the vulnerable roommate and described prior incidents of verbal abuse, threats toward other residents, and sufficient physical strength to move others, yet there was no documentation of enhanced supervision or targeted precautions for the vulnerable resident. After the vulnerable resident was found with significant bleeding, lacerations, and later diagnosed intracranial bleeding, facility leadership initially attributed the injuries to bed rails and the resident’s own teeth and did not include the aggressive roommate in the incident investigation, despite the aggressive history and later acknowledgment that the cheek puncture wounds could not have been self-inflicted.
The deficiency concerns the facility’s failure to thoroughly investigate several abuse-related incidents. In one case, a resident sustained facial lacerations and an intracranial hemorrhage, and leadership attributed the injuries to self-inflicted contact with bed siderails without investigating a former roommate known to have aggressive behaviors, despite external concerns about that roommate’s violent history. In another incident, a staff member reported seeing a CNA pull a resident by the wheelchair arm and yell at him, but the facility deemed the allegation unsubstantiated after the reporting employee resigned and conducted no further inquiry. In a third case, a resident reported that an RN threw a clipboard at him, resulting in a hand bruise, yet the facility relied on a reported retraction and the resident’s decision not to press charges to label the allegation unsubstantiated and document “confabulation,” even though the resident later stated he had not retracted the allegation and the only written investigation was a brief statement from the Risk Manager.
Surveyors found that the facility did not ensure accurate, resident-centered assessments and care plans when leadership directed the addition and repeated use of the term "confabulation" in several residents’ care plans and nursing notes without clear clinical rationale. One resident had confabulation added to the care plan after retracting an abuse allegation, another had a grievance about delayed incontinence care characterized as involving "some sort of confabulation," a third had multiple refusals of care documented as confabulation, and a fourth was described as confabulating after requesting to be changed again. The DSS, Administrator, and DON could not provide adequate justification for this pattern of documentation.
Surveyors found that staff documentation did not accurately reflect the actual condition and care needs of three residents. One paraplegic, bed-bound resident was charted as ambulating and transferring independently or with minimal assistance, despite staff confirming he was unable to walk or transfer. Another resident was documented on CNA flow sheets as independent with toileting, transfers, and lower body dressing and as having call light access and fluids at the hospital, while her care plan and staff interview described her as totally dependent with limited movement and needing feeding assistance. A third resident was charted as independent with toilet transfers and having no behaviors, even though nursing notes described episodes of yelling and screaming, the care plan showed total assistance needs and non-ambulatory status, and observation revealed he could not reposition himself in bed; a CNA stated he required total care and that behaviors were reported to nursing and recorded on a behavior flow sheet.
Staff used personal cell phones to photograph and video a resident experiencing pain and behavioral changes, as well as to routinely capture wound images, and then texted these images to the NP for assessment and treatment recommendations. A RN and the Wound Care Nurse reported storing these images on their personal devices and were unaware of any signed consents authorizing this method of communication. The Administrator did not object to the practice for medical purposes but acknowledged she could not ensure confidentiality once images were on staff devices. Facility policy required explicit written consent for imaging, prohibited unauthorized transmission of resident images, and treated photographs as health care records, yet there was no evidence of resident consent, authorization, or secure, encrypted transmission for the use of personal devices.
A resident with cognitive impairment sustained facial puncture wounds from contact with bed side rails, requiring sutures and hospital transfer. Although facility leadership was aware of the incident, it was not reported to authorities until after an APS investigator arrived, well beyond the facility’s policy requirement to report suspected abuse or injury of unknown origin within 2 hours when serious bodily injury is involved. The Risk Manager acknowledged that staff are expected to immediately report suspected abuse and injuries of unknown origin, but provided no reason for the reporting delay, resulting in noncompliance with the facility’s abuse reporting policy.
A dietary aide reported witnessing a staff member verbally and physically mistreat a resident in a wheelchair and then experienced ongoing harassment and retaliatory behavior from nursing and kitchen staff, including threatening comments, refusal to sign meal-tray forms, and aggressive, profane interactions. The aide, described by a coworker as quiet and respectful, ultimately resigned by phone, citing fear for personal safety and difficulty identifying harassing staff because they were not wearing name badges. Leadership, including the Administrator, DON, Risk Manager, Unit Manager, and HR Director, acknowledged awareness of harassment concerns but did not conduct an investigation into the reported retaliation, despite a written policy requiring protection of individuals who report suspected abuse.
A resident with a history of physical aggression was involved in an incident where they struck a nurse. Although staff began 15-minute checks following the event, this enhanced monitoring was not documented in the care plan or as a physician order. Interviews with the DON, social worker, and MDS nurse confirmed the omission of this intervention from the care plan.
A facility failed to assess a resident's capability to self-administer medications before allowing him to do so. The resident was observed performing his own tracheostomy care and had an unsecured tube of mupirocin ointment. Despite the facility's policy requiring an interdisciplinary team assessment and documentation, no such assessment was conducted for this resident.
A resident with a contracted hand and limited range of motion did not receive proper nail care, resulting in excessively long fingernails. The resident's care plan indicated dependency on staff for personal hygiene, but there was no documentation of nail care being performed or refused. The facility's policy required regular nail maintenance to prevent infections, which was not adhered to in this case.
A resident was observed with an undated dressing on the left lower arm over several days, with no order or documentation in the EMR for the skin tear. The wound care nurse confirmed the lack of documentation, and the DON stated that nurses are expected to notify providers of new skin issues and obtain treatment orders, which should be documented in the EMR.
A resident receiving Magnesium Oxide four times daily did not have their magnesium levels monitored as ordered by the physician. Despite an order for a magnesium level check every six months, no monitoring or documented refusal was found in the resident's record. The DON confirmed the oversight, which was contrary to the facility's policy requiring staff to arrange for necessary tests.
The facility failed to properly dispose of garbage and refuse, as observed during inspections of the kitchen and outside garbage bins. Trash was found around the garbage compactor, and a cardboard box bin had a hole, allowing contents to be visible. The Dietary Manager and Administrator acknowledged these issues, which were not in compliance with the facility's policy requiring safe and efficient disposal practices.
A facility failed to implement Transmission-Based Precautions (TBP) for a resident with an ESBL urinary tract infection (UTI). The resident's room lacked TBP signage and isolation setup, confirmed by the unit manager and infection preventionist. The facility's policy requires TBP for transmissible infections, but there was no clear process for monitoring new infections when the infection preventionist was not on site.
Failure to Address Aggressive Roommate Risk and Provide Adequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and precautions for a vulnerable resident when roomed with another resident who had a documented history of aggressive and violent behaviors. Resident #1 was a cognitively impaired, non-verbal, limited-mobility adult who sustained unwitnessed physical injuries on 01/30/2026, including lacerations that required transfer to a higher level of care, suturing, and diagnostic testing that revealed intracranial bleeding. Resident #6, who moved into Resident #1’s room on 12/23/2025, had a clinical record documenting aggressive and violent behaviors such as yelling and physically acting out toward other residents and staff. Despite this, Resident #1’s record contained no documentation of enhanced supervision or other specific precautions related to being roomed with Resident #6. Staff interviews further described a pattern of concerning behavior by Resident #6 that was not fully assessed or incorporated into supervision plans for Resident #1. A hospice CNA reported witnessing Resident #6 verbally cursing at Resident #1 prior to the 01/30/2026 incident. Another CNA, who discovered Resident #1 with significant blood on the bed rail, in her mouth, and on the floor, recalled that Resident #6 had previously become upset when Resident #1 made noise, had threatened another resident who sat in her chair, was often verbally abusive to other residents, and was physically strong enough to move Resident #1, though she had not personally witnessed physical altercations between the two roommates. A RN reported she had requested a room change for Resident #1 after staff notified her of Resident #6’s violent behaviors and that she had multiple attempts to contact the Administrator about this request. The facility’s Risk Manager and Administrator stated that the initial belief was that Resident #1’s injuries were caused by contact with the bed rails and her own teeth, and the Administrator acknowledged that the investigation of the 01/30/2026 incident did not include Resident #6 as a possible source of the injuries, despite Resident #6’s documented aggressive history and the later acknowledgment that the puncture wounds on the outside of Resident #1’s cheek could not have been caused by her teeth.
Failure to Thoroughly Investigate Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to conduct thorough investigations into multiple abuse-related incidents involving three residents. For one resident, the facility documented facial gashes after an event that required transfer to a higher level of care, suturing of two right lower facial lacerations, and identification of an intracranial hemorrhage. Facility leadership concluded the resident caused the injuries by striking her teeth on the bed siderails and stated they had no reason to investigate the resident’s former roommate, despite that roommate’s documented history of aggressive behaviors and prior episodes of becoming upset with other residents. Hospice staff had emailed the Administrator requesting the resident be moved due to concerns about the roommate’s history of violent behaviors, and the resident was moved several days after returning from the hospital. In a separate incident, the facility received an allegation of verbal abuse in which a dietary staff member reported witnessing a CNA pull a resident by the arm of his wheelchair and yell at him. The facility’s investigation concluded the allegation was unsubstantiated, citing an inability to obtain adequate information from the reporting staff member after his resignation, even though leadership knew he resigned due to workplace harassment following his report, and no further investigation was conducted. In another case, a resident alleged that an RN became upset and threw a clipboard at him, resulting in a documented bruise on his hand when he blocked the clipboard. Facility leadership stated the allegation was unsubstantiated based on a reported retraction relayed by the ADON and a note that the resident had signed something with the police; the IDT added “confabulation – allegations of staff abuse” to the resident’s record. However, the resident later stated he only declined to press charges and did not retract the allegation. The police report documented that the resident declined to press battery charges and that the Risk Manager questioned why the incident was reported two days after it occurred, and the facility’s investigation consisted only of the Risk Manager’s written statement that the resident declined to press charges, with no additional investigative documentation provided.
Inaccurate and Non–Resident-Centered Use of Confabulation in Care Plans and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident assessments and care plans were documented accurately and in a resident-centered manner for four residents. During interviews, the MDS LPN identified the Director of Social Services (DSS) as the person responsible for entering behavior items on residents’ care plans, and the DSS stated that such directives could come from upper management, including the Administrator, Risk Manager, or DON. When surveyors questioned why a care plan entry for confabulation was added for one resident shortly after that resident made allegations of abuse, the team did not answer, and the DSS deferred responsibility to the Administrator. In a follow-up interview, the Administrator and DON stated that this resident had retracted his statement of abuse and that this was the reason confabulation was added to his care plan. Further review showed that the term confabulation was also used in the documentation of three additional residents without clear clinical rationale provided by facility leadership. For one resident, confabulation was referenced in the summary of an investigation into a grievance in which the resident reported not being changed for 30 minutes after activating the call light, with the investigation summary stating there was “some sort of confabulation.” For another resident, confabulation was used in four nurses’ notes documenting that the resident refused care. For a fourth resident, confabulation was used in a nurse’s note stating that the resident requested to be changed after it had already been done. When asked, the Administrator and DON did not provide further explanation for the frequent use of confabulation in these residents’ charts.
Inaccurate ADL and Behavior Documentation for Dependent, Non-Ambulatory Residents
Penalty
Summary
The deficiency involves inaccurate and inconsistent medical record documentation for three residents, failing to reflect their actual functional status and behaviors. For one resident diagnosed with paraplegia, ADL documentation showed that he ambulated 150 feet independently or with varying levels of assistance and transferred from bed to chair independently or with supervision on multiple dates. However, observations on two consecutive days showed that he was bed bound with no active movement in his lower extremities, and both an LPN and a CNA confirmed he was paralyzed and unable to walk or transfer independently, stating that the documented entries would be impossible. For another resident, CNA flow sheets over a specified period documented independence with toilet and bed transfers, independence with lower body dressing, call light within reach, and fluids provided while at the hospital, while the resident’s care plan indicated total staff assistance. Observation showed this resident lying on her back with limited body movements, and a CNA later stated she required total care, had not been able to turn from side to side for several years, and required assistance with feeding. A third resident’s CNA flow sheets documented independence with toilet transfer and no behaviors, despite nursing notes on multiple dates describing the resident as upset, yelling, and screaming, and a care plan indicating a self-care deficit with total staff assistance for toileting, hygiene, and transfers, and that the resident was non-ambulatory. Observation showed this resident sliding down in bed and unable to reposition without assistance, and a CNA stated he required total care, while also explaining that behaviors were reported to the nurse and documented in a behavior flow sheet.
Unauthorized Use of Personal Cell Phones for Resident Images and Clinical Communication
Penalty
Summary
The facility failed to protect residents' personal privacy and the confidentiality of medical information when staff used personal cell phones to photograph and video residents for clinical communication with the facility’s Nurse Practitioner (NP). Nursing documentation showed that one resident was observed sliding on the floor while yelling and screaming with abdominal pain, and staff contacted the NP for clinical guidance. The NP’s written statement confirmed that staff provided a video of this resident and requested guidance based on the behaviors shown in the recording. During interviews, a RN admitted to taking a video of the resident on her personal cell phone to send to the NP and acknowledged knowing that personal devices were technically not permitted, though she believed the restriction related to posting on social media. The RN also reported that staff take photographs of residents’ skin concerns to send to the NP. The Wound Care Nurse stated that she routinely uses her personal cell phone to take and store pictures of residents’ wounds and sends them via text message to the NP for assessment and treatment recommendations, and both staff members were unaware of any signed consents from residents for this form of communication. The Administrator did not oppose the practice if done for medical purposes but acknowledged she could not ensure confidentiality once images were on personal devices. Review of the facility’s policy on videotaping, photographing, and imaging of residents showed requirements for explicit written consent, prohibition of unauthorized transmission of images, and treatment of photographs as health care records, but there was no evidence of consent, authorization, or secure, encrypted transmission for the use of staff personal devices as practiced.
Failure to Timely Report Suspected Abuse/Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to timely report an alleged incident of abuse/neglect within the required 2-hour timeframe. An incident report filed on 02/03/2026 at 4:00 PM documented an event as occurring on 02/03/2026, but further review showed the incident actually occurred on 01/30/2026. The event involved Resident #1, described as a vulnerable adult with cognitive impairment, who was found with her face pressed against the side rails of her bed on 01/30/2026, sustaining puncture wounds to the outside of her cheek that required sutures and a transfer to a local hospital. Although the report indicated the Administrator was notified on 02/03/2026, the Administrator was already aware of the incident that occurred on 01/30/2026. The incident was not reported to the appropriate authorities until after an Adult Protective Services investigator arrived at the facility on 02/03/2026 at 4:00 PM to investigate the allegation. During an interview on 02/09/2026, the facility Risk Manager stated she decided to report the incident after the APS investigator entered the facility and confirmed that her expectation is that any suspected abuse observed by staff must be reported immediately so she can initiate an investigation. She also stated that any injury of unknown origin must be reported within two hours, followed by a five-day report with investigation findings. The facility’s written policy on Abuse, Exploitation or Misappropriation-Reporting and Investigating, last revised 04/2021, requires that suspected abuse, neglect, or injury of unknown source be reported immediately to the administrator and other officials, defining “immediately” as within two hours for allegations involving abuse or resulting in serious bodily injury. The Risk Manager did not provide an explanation for the delay in reporting this incident, resulting in noncompliance with the facility’s policy and regulatory reporting timeframes.
Failure to Protect Abuse Reporter From Retaliation and Harassment
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse-prevention and anti-retaliation policies to protect an employee who reported alleged abuse of a resident. A dietary aide (Staff Q) reported witnessing a staff member pull Resident #4 by the wheelchair arm and tell the resident, “get your ugly *** out here,” and he immediately reported this to a Unit Manager, who then notified the Risk Manager. After making this report, Staff Q stated that staff spoke loudly about him in a threatening manner, made retaliatory remarks, refused to sign meal-tray forms, and used aggressive tones and profanity toward him. He reported ongoing harassment from both kitchen and nursing staff, but had difficulty identifying those involved because staff were not wearing name badges. Staff Q ultimately resigned by phone, stating he feared for his safety and reiterating that he could not positively identify all involved staff due to the lack of visible name badges. Multiple interviews with facility leadership and staff showed that no investigation into the reported harassment and retaliation was conducted, despite the facility’s written policy stating that the administrator ensures the person reporting suspected violations is protected from retaliation or reprisal. The Dietary Manager reported that when Staff Q told her he was resigning due to harassment after reporting abuse, she did not investigate the harassment herself but notified the Administrator and Risk Manager. The 3rd Floor Unit Manager acknowledged hearing that Staff Q resigned due to harassment but stated staff-to-staff harassment was outside her scope and should be handled by HR. The Risk Manager stated she attempted to contact Staff Q twice, was unable to reach him, and then unsubstantiated the abuse allegation without further investigation. The Administrator confirmed awareness that Staff Q reported being harassed but acknowledged that no investigation into the harassment occurred. A former dietary staff member (Staff R) also reported experiencing harassment from nursing and kitchen staff during his employment and stated he had reported it to HR, who told him to speak with his supervisor, who was allegedly involved in the harassment. The HR Director recalled a harassment report from Staff R, acknowledged uncertainty about the timeline, and admitted staff were “bad about wearing badges,” despite repeatedly instructing them to wear them.
Failure to Update Care Plan with Enhanced Monitoring After Aggressive Incident
Penalty
Summary
The facility failed to maintain a complete and comprehensive care plan for a resident with a history of physical aggression, including behaviors such as striking out, hitting, kicking, throwing objects, spitting at staff, and refusing care. On the morning of 5/27/25, staff responded to an incident where the resident was observed hitting a nurse in the dining room. Following the incident, the resident was seen by a Psychiatric APRN, and staff implemented 15-minute checks for the next 48 hours as a monitoring intervention. However, review of the resident's electronic medical record revealed that while the care plan for physical aggression was revised on the same day as the incident, no new interventions were documented, and the enhanced rounding of 15-minute checks was not added to the care plan. Additionally, there was no physician order for the enhanced rounding. Interviews with the DON, social worker, and MDS/care plan nurse confirmed that the care plan update for enhanced rounding was missed, and the intervention was not included in the resident's care plan.
Failure to Assess Resident's Capability for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team (IDT) assessed and determined if a resident was capable of self-administering medications before allowing a resident to do so. This deficiency was identified during an observation of a resident who was performing his own tracheostomy care and had an unsecured tube of mupirocin ointment on the sink. The resident had been declining tracheostomy care from staff and providing his own care on multiple occasions without an assessment to determine his capability to self-administer medications and treatments. The Director of Nursing (DON) acknowledged that the facility has a process to assess residents before allowing them to self-administer medications, but this process was not followed for the resident in question. The facility's policy requires that the IDT assess each resident's cognitive abilities to determine if self-administration is safe and appropriate, and this should be documented in the medical record and care plan. However, no such assessment or documentation was found for the resident, leading to the deficiency.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care to a resident who was dependent on staff for activities of daily living (ADL). During an observation, the Director of Nursing (DON) noted that the resident's fingernails on the right hand were excessively long, with the 5th digit's nail measuring 1.5 cm past the nail bed. The resident's right hand was contracted, making it difficult to measure the 4th digit's nail, which was also noted to be long. The DON confirmed that the nail length was unacceptable given the resident's condition. A review of the resident's records showed that the resident had a functional limitation in the range of motion on one side of the upper extremity and required supervision or assistance for personal hygiene. The care plan indicated the resident was dependent on staff for various personal care tasks, including nail care. However, there was no documentation of nail care being performed or any refusal of such care by the resident. The facility's policy on nail care, revised in February 2018, emphasized the importance of regular cleaning and trimming to prevent infections, but there was no record of compliance with this policy for the resident in question.
Failure to Document and Order Treatment for Skin Tear
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards and facility policy for a resident with a non-pressure related skin condition. Observations revealed that the resident had an undated dressing on the left lower arm over several days. The wound care nurse confirmed that the dressing was not dated and that there was no order for the dressing or documentation of the skin tear in the resident's electronic medical record (EMR). The wound was new to the wound care nurse that week, and no order had been obtained for the treatment. The Director of Nursing (DON) confirmed the absence of a documented order in the EMR for the resident's left lower arm/wrist area. The DON stated that it is expected for the nurse to notify the provider of any new skin issues, obtain an order for treatment, and document it in the EMR. Additionally, the resident's representative should be notified. The facility's policy on skin tears and minor breaks in the skin requires obtaining a physician's order, documenting physician notification, and reviewing the resident's care plan and current orders.
Failure to Monitor Magnesium Levels
Penalty
Summary
The facility failed to appropriately monitor the magnesium levels for a resident who was receiving Magnesium Oxide 400 mg by mouth four times a day since September 15, 2023. The physician had ordered a magnesium level to be checked every six months along with other routine labs, as per the order dated July 6, 2023. However, a review of the resident's record revealed that there was no monitoring of the magnesium level or any documented refusal of the test since the order date. An interview with the Director of Nursing confirmed that the magnesium level was not completed, and there were no documented attempts or refusals in the resident's record. The facility's policy, Lab and Diagnostic Test Results-Clinical Protocol, revised in November 2018, states that the physician will identify and order diagnostic and lab testing based on the resident's needs, and the staff will process test requisitions and arrange for tests. Despite this policy, the necessary monitoring was not conducted, leading to a deficiency in the resident's care.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during an inspection of the kitchen and outside garbage collection bins. On the initial tour, trash was found around the garbage compactor, and a cardboard box trash bin was on the ground with a visible hole in the forklift port, allowing cardboard boxes to be seen through it. The Dietary Manager acknowledged the issues, indicating plans to notify the Maintenance Manager about the hole and to clean up the area. A follow-up observation confirmed the ongoing issues, with the Administrator noting the hole in the cardboard box bin and trash scattered on the ground around the bins. The facility's policy, dated October 2019, requires that garbage and refuse be collected and disposed of safely and efficiently, with specific responsibilities assigned to the Dining Services Director and the Director of Maintenance to maintain cleanliness and proper disposal practices.
Failure to Implement Transmission-Based Precautions for ESBL UTI
Penalty
Summary
The facility failed to implement Transmission-Based Precautions (TBP) for a resident diagnosed with an extended-spectrum B-lactamase (ESBL) urinary tract infection (UTI). On September 10, 2024, the room of Resident #8 was observed without TBP signage or any isolation setup, including personal protective equipment (PPE). This was confirmed by the unit manager, Staff K, who acknowledged that residents with ESBL UTI should be on contact precautions, which include TBP signage and isolation setup by the door. The infection preventionist (IP) confirmed that an order for antibiotics was placed on September 6, 2024, and that the resident should have been placed on contact isolation at that time. Further interviews revealed a lack of a clear process for monitoring new infections when the IP is not on site. Staff K was unaware of any such process, and the Director of Nursing (DON) stated that the house supervisor reviews orders on weekends for residents being readmitted from the hospital. However, there was no indication that this process was followed for Resident #8. The facility's policy on Isolation-Initiating Transmission Based Precautions, revised in August 2019, states that such precautions should be initiated when a resident has a laboratory-confirmed infection and is at risk of transmitting it to others, which was not adhered to in this case.
Latest citations in Florida
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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