Glades Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pahokee, Florida.
- Location
- 230 South Barfield Highway, Pahokee, Florida 33476
- CMS Provider Number
- 106018
- Inspections on file
- 15
- Latest survey
- December 5, 2024
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Glades Health Care Center during CMS and state inspections, most recent first.
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 the facility did not perform and/or could not document the required annual 90‑minute test of battery-powered emergency lighting as required by NFPA 101 (2012 and 2021). During a record review with the Maintenance Director, no records were available to show that the annual 90‑minute emergency lighting test had been completed, and the Maintenance Director acknowledged the absence of this documentation, resulting in a cited deficiency affecting all occupants of the building.
Surveyors found that the facility failed to maintain required fire alarm system documentation and testing records. During record review with the Maintenance Director, there was no vendor-signed log book at the fire panel documenting work performed at each visit, no documentation of biennial smoke detector sensitivity testing, and no fire alarm system design plans located at the fire panel, as required by NFPA 101 and NFPA 72.
Surveyors found that the facility failed to maintain required documentation for multiple fire protection system tests and inspections, including the annual fire hydrant flow test, the five-year GPM test of the hydrant, the five-year internal inspection of the fire riser, and the five-year hydrostatic test of the FDC, as required by NFPA 101 and NFPA 25. In addition, the facility lacked records of required fire drills for each shift per quarter, with missing drills for one quarter’s third shift and for the second and third shifts of the last quarter of the prior year. The Maintenance Director acknowledged that these records were not available.
Surveyors found that the facility did not comply with NFPA 101 fire drill requirements when record review with the Maintenance Director showed missing documentation of quarterly fire drills for the third shift in one quarter and for the second and third shifts in another quarter. Required drills, which must simulate emergency fire conditions and include fire alarm activation or coded announcements at night, were not documented as completed for these periods. The Maintenance Director acknowledged the absence of records, and the deficiency was cited under NFPA 2021 19.7.1 as a Class III violation affecting all occupants.
Surveyors found that the facility did not perform or could not document required annual testing of electrical receptacles for tension and polarity in patient care areas, as mandated by NFPA 99. During record review with the Maintenance Director, no evidence was produced to show that hospital‑grade and other required receptacles had been tested at the specified intervals, and the Maintenance Director acknowledged this lack of documentation. This noncompliance with NFPA 99 Section 6.3.4 was cited as a deficiency affecting all occupants who rely on the facility’s electrical systems.
Surveyors found that the facility did not have documentation showing that the essential electrical system’s main and feeder circuit breakers were exercised annually in accordance with manufacturer recommendations and NFPA 99 requirements. During record review with the Maintenance Director, no records could be produced to verify that these breakers had been properly exercised, and the Maintenance Director acknowledged this failure. This deficiency was cited as affecting all occupants due to noncompliance with required essential electrical system maintenance and testing standards.
Surveyors found that the facility did not maintain required documentation showing that annual NFPA 99-compliant testing (including physical integrity, resistance, leakage current, and touch current tests) was performed on electrical equipment used for patient care. During record review with the Maintenance Director, no records could be produced to verify that this testing had been completed as required, and the Maintenance Director acknowledged the lack of documentation.
Surveyors observed that more than 12 "E" oxygen cylinders (18 total) were stored in a sprinkler room within five feet of combustible materials, contrary to NFPA 99 requirements for gas equipment cylinder storage. The Maintenance Director confirmed this storage practice during the survey. This noncompliance with NFPA 99 sections 11.3.1–11.3.3 was cited as a deficiency affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to maintain its sprinkler system’s fire riser in proper working order, as evidenced by multiple red tags from the sprinkler vendor and lack of supporting documentation. When the system was not fully functional, the facility did not notify the Agency for Health Care Administration or local fire rescue as required, and did not initiate a fire watch. The Maintenance Director and the Administrator acknowledged that these notifications and the fire watch were not carried out, creating a deficiency that could affect all occupants during a fire or other emergency.
Surveyors found that the facility installed a 250 KW generator outside directly in front of four rooms, including room 30, without submitting required construction plans to the Agency’s Office of Plans and Construction as mandated by FAC 59A-4.134 and the Florida Building Code. During record review with the Maintenance Director and the Administrator, the facility could not provide documentation that these rooms would never be used as patient rooms, despite the generator’s location. The facility leadership acknowledged the lack of required documentation and failure to obtain prior written approval, a deficiency that the surveyors noted could affect all occupants in the event of a fire or other emergency.
Surveyors found that the facility did not comply with FAC 59A-4.126 requiring semiannual testing of its emergency management plan. During record review with the Maintenance Director and the Administrator, the facility was unable to produce documentation that the emergency management plan had been tested as required, either through actual events or planned drills. Both the Maintenance Director and the Administrator acknowledged the absence of documentation, and the deficiency was cited as a Class III violation with the potential to affect all occupants during a fire or other emergency.
Surveyors found that the facility did not comply with NFPA 99 (2021) requirements for security management because it lacked documentation showing that its Security Vulnerability Assessment (SVA) was updated and reviewed on an annual basis. During record review with the Maintenance Director and the Administrator, no current or yearly SVA documentation could be produced, and both leaders acknowledged that the assessment had not been updated and reviewed each year, resulting in a cited Class III deficiency affecting all occupants in the event of a fire or other emergency.
A facility failed to ensure proper oversight in nutritional assessments, as a CDM conducted quarterly assessments for a resident with multiple health issues without Dietitian review. The Dietitian was unaware of the need for oversight, leading to a deficiency affecting the resident and potentially impacting others.
The facility did not follow the approved menu during a lunch service, substituting chicken and green beans for the planned BBQ ribs and corn on the cob. Residents with pork dislikes were affected, as they were not informed of the alternate meal options. The kitchen manager confirmed the oversight and acknowledged the absence of planned vegetables.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling medical devices, affecting multiple residents. Observations revealed a lack of EBP measures, such as signage and PPE kits, and staff did not adhere to hand hygiene protocols during care. Interviews indicated a lack of staff awareness and understanding of EBP and PPE requirements, contributing to the deficiency.
The facility failed to ensure accurate MDS assessments for three residents, leading to deficiencies in care. A resident with dementia was inaccurately assessed as having no upper extremity impairment, despite needing a hand splint. Another resident was recorded as having adequate hearing, despite severe hearing loss and lack of hearing aids. Additionally, a resident on anti-platelet medication had no documentation of this in the MDS, despite its confirmed administration.
The facility failed to develop comprehensive care plans for two residents. One resident with severe cognitive impairment experienced a fall resulting in a thumb dislocation, but the care plan was not updated to address the injury or splint care. Another resident was observed using bed side rails, but this was not documented in the care plan. The MDS Coordinator acknowledged these deficiencies.
A resident with severe cognitive impairment and an indwelling urinary catheter did not receive proper personal care from a CNA, who failed to perform hand hygiene before donning gloves and did not provide necessary peri-care. The resident's care plan noted potential complications from catheter use, and the resident was colonized with E. Coli, indicating improper catheter care.
The facility failed to ensure that fried fish was cooked to a safe temperature for a resident. The fish was initially fried and placed on the steam table without checking its temperature, which was later found to be 125 degrees F, below the required 145 degrees F. After further cooking, the temperature reached 164 degrees F. The Kitchen Manager acknowledged the failure to properly check and maintain the safe temperature.
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.
Failure to Perform and Document Annual 90‑Minute Emergency Battery Lighting Test
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual 90‑minute testing of battery-powered emergency lighting in accordance with NFPA 101 (2012 and 2021 editions), Sections 18.2.9.1 and 19.2.9.1. During a record review conducted between 9:15 AM and 1:30 PM with the Maintenance Director, surveyors were unable to locate documentation showing that the annual 90‑minute emergency battery lighting test had been completed. The Maintenance Director acknowledged that the facility could not provide documentation that this required annual 90‑minute testing of the battery lighting was performed. The deficiency was cited as affecting all occupants of the building under NFPA 101 2012 and 2021, 19.2.9.1, Class III. No specific residents, medical histories, or clinical conditions were mentioned in the report, and the findings were limited to the facility’s emergency lighting testing and documentation practices as observed during the surveyor’s record review and staff interview.
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. The 90 minute battery lighting test was completed and documentation is placed in the maintenance director book. 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 for three months random checks of completed documentation. 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. The 90 minute battery lighting test was completed and documentation is placed in the maintenance director book 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.
Failure to Maintain Required Fire Alarm Documentation and Testing Records
Penalty
Summary
Surveyors identified deficiencies related to the facility’s fire alarm system testing and maintenance during record review with the Maintenance Director between 9:15 AM and 1:30 PM. The facility did not have a log book located at the fire alarm panel that was signed by the fire alarm vendor and documented the work completed at each visit, as required by NFPA 101 and NFPA 72. The Maintenance Director acknowledged that the facility failed to provide this log book at the fire panel. Additionally, the facility was unable to provide documentation that biennial smoke detector sensitivity testing had been performed, and the Maintenance Director confirmed that this documentation was not available. Surveyors also found that the fire alarm system design plans were not located at the fire panel as required. The Maintenance Director acknowledged that the facility failed to provide the fire alarm system design plans at the fire panel. These findings were cited under NFPA 101 2021 sections 9.6.5 and 9.6.7 and NFPA 72.
Plan Of Correction
The fire alarm book was placed at the fire panel with the pull station zones and building map. (Fire Alarm System Design Plan) This was completed on [R] The biennial sensitivity testing on the smoke detectors was completed on [R] 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 for a period of three months a random audit of completed documentation. The fire alarm book was placed at the fire panel with the pull station zones and building map. (Fire Alarm System Design Plan) This was completed on The biennial sensitivity testing on the smoke detectors was completed on 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 for a period of three months a random audit of completed documentation,
Failure to Maintain Sprinkler System Testing and Fire Drill Documentation
Penalty
Summary
Surveyors identified deficiencies related to the facility’s failure to maintain and test its automatic sprinkler and associated fire protection systems in accordance with NFPA 101 and NFPA 25. During record review between 9:15 AM and 1:30 PM with the Maintenance Director, the facility was unable to provide documentation that an annual flow test had been performed on the on-site fire hydrant as required. The Maintenance Director acknowledged that the facility failed to provide documentation that this annual hydrant flow test was completed. Further record review during the same time period showed that the facility also lacked documentation of the required five-year gallons-per-minute (GPM) testing of the fire hydrant. In addition, the facility could not produce records showing that a five-year internal inspection of the fire riser had been performed. The Maintenance Director acknowledged the absence of documentation for the five-year internal riser inspection. Surveyors also found that the facility failed to provide documentation that a five-year hydrostatic test of the Fire Department Connection (FDC) had been completed. Separately, the surveyors reviewed fire drill records and determined that the facility did not have documentation of required fire drills for each shift per quarter. Specifically, fire drills were missing for the third shift of the first quarter of one year and for the second and third shifts of the last quarter of the prior year. The Maintenance Director acknowledged that the facility failed to provide documentation that these fire drills were performed.
Plan Of Correction
The five year gallon per minute testing was completed on [R] The five year internal inspection was performed on the riser on [R] The five year hydrostatic testing was performed and completed on [R] The five year gallon per minute testing on the fire hydrant was completed on [R] 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 for a period of three months a random audit of completed documentation. The five year gallon per minute testing was completed on [R] The five year internal inspection was performed on the riser on [R] The five year hydrostatic testing was performed and completed on [R] The five year gallon per minute testing on the fire hydrant was completed on [R] 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 for a period of three months a random audit of completed documentation.
Failure to Conduct and Document Required Quarterly Fire Drills on All Shifts
Penalty
Summary
Surveyors identified a deficiency related to fire drill compliance and documentation under NFPA 101 (2021). During record review conducted between 9:15 AM and 1:30 PM with the Maintenance Director, the facility was unable to provide documentation that required fire drills had been performed. Specifically, fire drills were missing for the first quarter of 2026 on the third shift, as well as for the second and third shifts of the last quarter of 2025. The cited regulations require that fire drills in health care occupancies simulate emergency fire conditions, include activation of the fire alarm system notification appliances (with limited exceptions for nighttime coded announcements), and be conducted at least quarterly on each shift. The survey findings noted that these missing drills and lack of documentation represented a failure to comply with NFPA 101 2021, Section 19.7.1, which mandates quarterly fire drills on each shift to familiarize personnel with emergency signals and required actions. The Maintenance Director acknowledged that the facility failed to provide documentation that the fire drills were performed for the identified quarters and shifts. The deficiency was classified under NFPA 2021 19.7.1 as a Class III violation and was determined to have the potential to affect all occupants in the facility in the event of a fire or other emergency.
Plan Of Correction
Facility conducted fire drills on all three shifts. These drills were done on [R] , and [R] . 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 for a period of three months a random audit of completed documentation. Facility conducted fire drills on all three shifts. These drills were done on [R] , [R] , and [R] . 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 for a period of three months a random audit of completed documentation.
Failure to Perform and Document Required Annual Receptacle Testing
Penalty
Summary
The deficiency involves the facility’s failure to comply with NFPA 99 requirements for electrical systems maintenance and testing, specifically related to receptacle testing for tension and polarity. During a record review conducted between 9:15 AM and 1:30 PM with the Maintenance Director, surveyors requested documentation showing that hospital‑grade and other required receptacles at patient care locations had been tested at the required intervals. The facility was unable to provide documentation that annual testing for receptacle tension and polarity had been performed as required by NFPA 99 (referenced as both the 2012 and 2021 editions in the report). The Maintenance Director acknowledged that the facility failed to provide documentation demonstrating that the required annual receptacle testing for tension and polarity had been completed. The report notes that this failure to maintain and document testing of electrical receptacles could affect all occupants in the facility in the event of a fire or other emergency. No specific residents, clinical conditions, or individual patient events are described in the report; the deficiency is based solely on the absence of required testing records and the associated noncompliance with NFPA 99 Section 6.3.4 for Class III electrical systems.
Plan Of Correction
The Tension and Polarity test was performed throughout the building and completed on .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 for a period of three months a random audit of completed documentation. The Tension and Polarity test was performed throughout the building and completed on [R] . 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 for a period of three months a random audit of completed documentation.
Failure to Exercise and Document Main and Feeder Breaker Maintenance per NFPA 99
Penalty
Summary
The deficiency involves the facility’s failure to maintain and document required maintenance and testing of the essential electrical system’s main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 9:15 AM and 1:30 PM with the Maintenance Director, surveyors requested documentation showing that the main and feeder breakers had been exercised annually as required. The facility was unable to provide records demonstrating that these breakers were exercised per the manufacturer’s recommendations. The Maintenance Director acknowledged that the facility failed to provide documentation that the main and feeder breakers were exercised according to the manufacturer’s recommendations. This lack of documentation and evidence of required exercising of the breakers was cited as noncompliance with NFPA 99 (referencing sections 6.4.4, 6.5.4, 6.6.4/6.5.4 Class III) and related standards governing essential electrical system maintenance and testing. The deficiency was noted as having the potential to affect all occupants in the facility in the event of a fire or other emergency.
Plan Of Correction
A generator load test was performed on . Documentation of work performed is in the record book and print out from machine is also onThe 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 for a period of three months a random audit of completed documentation. K0918 A generator load test was performed on [R] Documentation of work performed is in the record book, and print out from machine is also on [R] 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 for a period of three months a random audit of completed documentation.
Failure to Maintain Annual Testing Documentation for Patient-Care Electrical Equipment
Penalty
Summary
The deficiency involves the facility’s failure to comply with NFPA 99 requirements for testing and maintenance of patient-care-related electrical equipment (PCREE). During a record review conducted between 9:15 AM and 1:30 PM with the Maintenance Director, surveyors requested documentation showing that physical integrity, resistance, leakage current, and touch current tests were performed on electrical equipment used for patient care. The facility was unable to provide documentation that this electrical testing was completed on an annual basis as required by NFPA 99. The Maintenance Director acknowledged that the facility failed to provide documentation demonstrating that annual electrical testing of equipment used for patient care had been completed. The deficiency was cited under NFPA 99 (referencing sections 10.3, 10.5.2.1, and 10.5.2.5, among others) and was noted as affecting all occupants in the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were described in the report.
Plan Of Correction
The testing of electrical equipment was performed by DESCO throughout the building. A report has been provided and work was completed on . 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 for a period of three months a random audit of completed documentation. The testing of electrical equipment was performed by DESCO throughout the building. A report has been provided and work was completed onThe 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 for a period of three months a random audit of completed documentation.
Improper Storage of Oxygen Cylinders Near Combustibles
Penalty
Summary
The deficiency involves improper storage of medical gas cylinders, specifically more than 12 "E" oxygen tanks, in violation of NFPA 99 requirements. During an observation at 4:30 PM with the Maintenance Director, surveyors noted that 18 "E" tanks were being stored in a sprinkler room. These cylinders were located within five feet of combustible materials, contrary to NFPA 99 (2012 and 2021 editions), which requires that oxidizing gas cylinders in quantities greater than 300 cubic feet be separated from combustibles by at least 20 feet (or 5 feet if the area is sprinklered) or stored in an appropriately rated noncombustible cabinet. The report states that the storage arrangement did not comply with NFPA 99 sections 11.3.1, 11.3.2, and 11.3.3, which govern gas equipment cylinder and container storage, including separation from combustibles. The Maintenance Director acknowledged during the survey that 18 "E" tanks were stored in the sprinkler room within five feet of combustibles. The deficiency is cited as affecting all occupants in the facility in the event of a fire or other emergency, and no additional resident-specific clinical details are provided in the report.
Plan Of Correction
tank cylinders were removed from certain locations and the number of tanks were reduced in those locations. The tanks were relocated to a locked designated area. This was completed on . [R] tank cylinders were removed from certain locations and the number of tanks were reduced in those locations. The tanks were relocated to a locked designated area. This was completed on [R] . 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 for a period of three months a random audit of completed documentation.
Failure to Maintain Sprinkler System and Implement Required Notifications and Fire Watch
Penalty
Summary
Surveyors identified a deficiency related to fire protection and life safety requirements under 59A-4.130 and NFPA 101. During record review between 9:15 AM and 1:30 PM with the Maintenance Director, the facility could not provide documentation that the fire riser and associated sprinkler system were maintained in proper working order. Three red tags from the sprinkler vendor were observed on the sprinkler system since 2025, indicating unresolved issues with the system’s status. The facility also failed to follow required procedures when the fire protection system was not fully functional. Specifically, the facility did not notify the authorities having jurisdiction, including the Agency for Health Care Administration and Palm Beach County Fire Rescue, as required when there is a system failure of the sprinkler system. In addition, the facility did not implement a fire watch during the period when the sprinkler system was not in proper working order. The Maintenance Director and the Administrator acknowledged these failures to notify the appropriate authorities and to initiate a fire watch. This deficiency had the potential to affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
The facility placed itself on a self imposed fire watch due to the red tags given to us from our sprinkler system vendor. The fire watch started on [R] and is still on-going pending the final report from our vendor. The facility notified the local area office of AHCA and the Fire Marshall of the Palm Beach Fire Rescue. The facility notified both parties on [R]. Daily logs are being sent to the AHCA surveyor and the fire Marshall. 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 for a period of three months a random audit of completed documentation.
Failure to Submit Required Construction Plans Before Generator Installation
Penalty
Summary
The deficiency involves the facility’s failure to comply with Florida Administrative Code 59A-4.134 and the Florida Building Code requirements for plans submittal prior to construction work. Surveyors, during record review with the Maintenance Director and the Administrator between 9:15 AM and 1:30 PM, determined that the facility did not submit required plans to the Agency’s Office of Plans and Construction before installing a 250 KW generator outside the building. This generator was installed directly in front of four identified rooms, including room 30, without prior written approval or documented review by the Office of Plans and Construction as required for construction, additions, or modifications. During the review, the facility was unable to provide documentation that these four rooms, including room 30, would never be used as patient rooms, despite the generator’s placement directly in front of them. The Maintenance Director and the Administrator acknowledged that the facility failed to provide such documentation and that plans had not been submitted to the Office of Plans and Construction before the generator installation. The survey findings state that this failure to submit plans and obtain approval before the work could affect all occupants in the facility in case of a fire or other emergency.
Plan Of Correction
The following resident room numbers 24, 25, 28, and 30 have been decommissioned and have been taken out of service until the generator is relocated. The four rooms will remain out of service until the project is complete and deemed in compliance by AHCA. A submission for the relocation of the generator will be sent to the Office of Plans and Construction for a full plan review. This submission to the OPC will occur no later than . Upon approval of the project from OPC with an issued project number, the relocation of the generator will immediately be initiated. The facility has determined that all residents have the potential to be affected. An in-service education will be conducted by the administrator. The administrator will conduct a three month review of all necessary paperwork for relocation paperwork.
Failure to Conduct and Document Semiannual Emergency Management Plan Testing
Penalty
Summary
The facility failed to comply with Florida Administrative Code 59A-4.126, which requires a written, comprehensive emergency management plan to be tested semiannually, either in response to an actual disaster/emergency or through a planned drill. During record review between 9:15 AM and 1:30 PM with the Maintenance Director and the Administrator, surveyors requested documentation of the semiannual testing of the emergency management plan. The facility was unable to provide any documentation showing that these required semiannual tests had been performed. The Maintenance Director and the Administrator acknowledged that the facility failed to provide documentation that the semiannual testing of the emergency management plan was performed. This deficiency was cited as a Class III violation and was noted as having the potential to affect all occupants in the facility in case of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report, and the deficiency centered solely on the lack of documented semiannual testing of the emergency management plan.
Plan Of Correction
The facility ran in-service drill for internal and external drills. Paperwork is in the log book in the maintenance director's books. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted. The administrator will conduct a three month check to verify completion of documentation.
Failure to Annually Update and Review Security Vulnerability Assessment
Penalty
Summary
The facility failed to comply with NFPA 99 (2021 Edition) security management requirements by not maintaining an annually updated and reviewed Security Vulnerability Assessment (SVA). During record review between 9:15 AM and 1:30 PM with the Maintenance Director and the Administrator, surveyors requested documentation showing that the SVA had been updated and reviewed each year, as required by Section 13.3 of NFPA 99. The facility was unable to provide such documentation, and both the Maintenance Director and the Administrator acknowledged that the Security Vulnerability Assessment had not been updated and reviewed annually. This deficiency was cited as a Class III violation and was noted as having the potential to affect all occupants in the facility in case of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report, and the deficiency pertained to facility-wide security and emergency preparedness documentation rather than to individual patient care events.
Plan Of Correction
Security vulnerability assessment was reviewed and a signature page was placed in the binder. 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 a three month check to verify completion of documentation.
Deficiency in Nutritional Assessment Process
Penalty
Summary
The facility failed to ensure that clinical nutritional assessments were completed within the appropriate scope of practice, affecting one resident reviewed for nutrition and potentially impacting 51 out of 60 residents. The Certified Dietary Manager (CDM) conducted quarterly nutritional assessments for a resident with multiple diagnoses, including Diabetes, Hypertension, Congestive Heart Failure, and Anemia, without oversight or review by the facility's Dietitian. The CDM completed these assessments using a formula provided by the Dietitian but did not have the assessments signed off by the Dietitian. Interviews revealed that the CDM was responsible for most quarterly assessments, while the Dietitian handled initial, annual, and specific cases such as tube feedings, dialysis, and weight loss. The Dietitian was unaware that the CDM should not perform quarterly assessments without oversight. The CDM communicated with the Dietitian regarding weight changes but did not have the assessments formally reviewed or acknowledged by the Dietitian, leading to a deficiency in the facility's nutritional assessment process.
Failure to Follow Approved Menu and Provide Alternate Meal Options
Penalty
Summary
The facility failed to adhere to their approved menu during a lunch meal service, affecting the nutritional needs of residents. On the observed date, the approved menu included BBQ ribs with baked beans and an alternate meal of fried fish with corn on the cob. However, the actual meal served included chicken thighs and green beans, with no corn on the cob, carrots, or lima beans prepared as per the menu. The lead cook admitted to substituting green beans for carrots and chicken for fish, citing resident preferences, but could not explain the absence of corn on the cob or lima beans. The kitchen manager confirmed the availability of corn on the cob in the freezer but had no explanation for its omission, and acknowledged the lack of carrots and lima beans. The deficiency affected residents who had documented dislikes for pork, as the main entree was pork BBQ ribs. One resident who disliked pork was served fried fish, while others received chicken, contrary to the documented alternate meal. Interviews with residents revealed dissatisfaction with the meal substitutions, as one resident expressed a preference for the corn on the cob that was not served. Another resident confirmed receiving chicken without being informed of the alternate meal option of fried fish, which he preferred. The kitchen manager acknowledged the oversight in meal preparation and confirmed the mechanical soft and pureed vegetable options should have been corn, aligning with the alternate vegetable choice.
Failure to Implement Enhanced Barrier Precautions and Ensure Hand Hygiene
Penalty
Summary
The facility failed to implement an Enhanced Barrier Precaution (EBP) process for residents with wounds and indwelling medical devices, affecting four sampled residents and potentially impacting six residents identified as needing EBP. This deficiency was observed in residents with conditions such as dementia, end-stage renal disease, and urinary catheter use. The facility's infection preventionist admitted that the EBP process was not in place until after the surveyor's intervention, indicating a lack of adherence to infection control practices. Resident #22, who was receiving tube feeding, was observed multiple times without any EBP measures in place, such as signage or a PPE kit. Similarly, Resident #44, who had a stage four pressure ulcer, was observed without EBP measures during wound care. Staff involved in the care of Resident #44 did not wear gowns, and hand hygiene was not performed between glove changes, contrary to the facility's policy. The staff's lack of understanding and adherence to EBP and hand hygiene protocols contributed to the deficiency. Additionally, Resident #1, who had a urinary catheter, was observed without EBP measures, and staff were unaware of the necessary PPE requirements. Interviews with staff revealed a lack of awareness and understanding of EBP, with some staff unable to locate necessary PPE supplies. The facility's failure to ensure appropriate infection control practices and staff education on EBP and PPE use led to the identified deficiencies.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in their care. Resident #15, who was admitted with dementia, was inaccurately assessed as having no impairment in upper extremities, despite therapy evaluations and care plans indicating the need for a right-hand splint and passive range of motion exercises due to right-sided weakness. Observations confirmed the resident's right hand was tightly closed with contracture, and no splint was in place, contradicting the MDS assessment. The MDS Coordinator acknowledged the discrepancy during a review. Resident #33, admitted with hypertension, was recorded in the MDS as having adequate hearing, despite care plans and progress notes indicating severe hearing loss. Observations and family interviews confirmed the resident's inability to hear and lack of hearing aids, which were discarded. The MDS Coordinator agreed with the incorrect coding. Additionally, Resident #8, who was on anti-platelet medication for a stroke, had no documentation of this medication in the MDS assessment, although the Medication Administration Record confirmed its administration. The MDS Coordinator acknowledged the failure to code the medication correctly.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop adequate care plans for two residents, leading to deficiencies in their care. Resident #58, who had severe cognitive impairment and a history of falls, experienced a fall resulting in a thumb dislocation. Despite the incident, the care plan was not updated to address the actual fall with injury or the necessary splint care. The MDS Coordinator acknowledged the absence of a specific care plan for the significant injury from the fall and the lack of a care plan related to splint care. Resident #17 was observed using bed side rails, but the facility did not include this in the resident's care plan. The MDS Coordinator, who was new to the facility, noted inconsistencies in the care plans and agreed that the use of bed side rails should have been documented. The failure to include the use of bed side rails in the care plan for Resident #17 was acknowledged during the survey.
Deficiency in Catheter Care and Personal Hygiene
Penalty
Summary
The facility failed to provide complete and proper personal care for a resident with a urinary drainage device. The deficiency was identified during an observation of personal care provided by a Certified Nursing Assistant (CNA) to a resident who was cognitively impaired and totally dependent on staff for toileting. The CNA did not perform hand hygiene before donning gloves, which is a requirement according to the facility's policy on Foley catheter care and maintenance. Additionally, the CNA did not provide peri-care during the catheter care process, which is essential to prevent complications such as infections. The resident, who had an indwelling urinary catheter due to bladder obstruction, was observed in bed with urinary catheter tubing and bedside drainage. The CNA cleaned the urinary catheter tubing and the resident's left groin but failed to perform any peri-care. When questioned, the CNA admitted to not providing any personal care for the resident that morning and confirmed the lack of hand hygiene before donning gloves. The resident's care plan noted a potential for complications related to the use of an indwelling catheter, and it was updated to reflect colonization with E. Coli, indicating a lapse in proper catheter care.
Failure to Ensure Safe Cooking Temperature for Fried Fish
Penalty
Summary
The facility failed to follow proper cooking instructions and ensure that prepared fried fish was at a safe temperature for a resident who ordered the meal. The production recipe for the breaded cod specified that the fish should be deep-fried from frozen at 360 degrees F for 3 to 5 minutes, with a final internal cooking temperature of at least 145 degrees F, held for a minimum of 15 seconds. Additionally, hot foods held for later service must maintain a minimum internal temperature of 135 degrees F. During the lunch meal service, the lead cook placed prepared foods into the steam table and stated that the fried fish would be cooked later, as the resident who requested it was served on the last cart. At approximately 12:00 PM, the assistant cook fried three pieces of fish and placed them on the steam table without obtaining a final temperature. When the surveyor requested the temperature of the fish at 12:14 PM, it was found to be 125 degrees F, which was below the required safe temperature. The lead cook instructed the assistant cook to fry the fish longer, and after further cooking and surveyor intervention, the temperature reached 164 degrees F. The Kitchen Manager/Certified Dietary Manager acknowledged that the staff failed to properly check the temperature of the fried fish upon completion of cooking and did not hold the cooked fish at a safe temperature.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
