Golfcrest Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hollywood, Florida.
- Location
- 600 North 17th Ave, Hollywood, Florida 33020
- CMS Provider Number
- 105009
- Inspections on file
- 20
- Latest survey
- May 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Golfcrest Nursing Center during CMS and state inspections, most recent first.
A resident with recent major surgery and complex care needs was admitted without timely physician orders for pain management, surgical site care, or Foley catheter care. Facility staff did not complete required pain assessments or administer routine and as-needed medications until the day after admission, despite clear hospital discharge instructions and family concerns. Nursing staff acknowledged not contacting the physician or documenting pain assessments as required by facility policy.
The facility failed to provide adequate care, including timely medication administration, accurate skin condition documentation, and proper nutritional support. A resident experienced a delay in receiving medication after abnormal lab results, another had exposed skin areas not documented, and a third suffered significant weight loss due to inadequate nutritional assessments and interventions.
A facility failed to provide timely nutritional assessments and interventions, leading to significant weight loss for a resident. Inconsistent application of dietary orders and inaccurate recording of food intake contributed to the deficiency. Another resident had overlapping enteral feeding orders, resulting in improper administration, while a third resident's feeding regimen was not followed, despite a risk for malnutrition. The facility's failure to adhere to physician orders and properly monitor feeding regimens led to these nutritional deficiencies.
The facility failed to develop and implement comprehensive care plans for two residents. One resident's care plan was not updated to address a resolved skin condition and lacked preventive measures for new issues. Another resident had no care plan for medications prescribed for agitation, with no monitoring for side effects. The MDS Coordinator acknowledged these oversights.
The facility was found deficient in maintaining a safe, clean, and homelike environment for residents. Observations revealed issues such as peeling paint, dust-covered fans and vents, uncovered fluorescent bulbs, missing light bulbs, unpainted plaster, leaky faucets, and improperly wrapped call light cords. These findings were acknowledged by the new Director of Maintenance and Administrator during a tour with surveyors.
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency in accommodating their needs. One resident was observed with the call light out of reach multiple times, requiring them to yell for assistance. Another resident was found banging on her table and yelling for help due to an inaccessible call light. Staff interviews confirmed that call lights should be within reach, but this was not the case for these residents.
The facility failed to provide a safe, clean, and homelike environment for residents, with issues such as peeling paint, dusty fans, uncovered fluorescent bulbs, and leaky faucets observed in several rooms. These deficiencies were acknowledged by the new Director of Maintenance and Administrator.
A facility failed to develop and implement comprehensive care plans for two residents. One resident's care plan was not updated to reflect the resolution of a skin condition, and there were no preventive interventions. Another resident had no care plan for medications prescribed for agitation, lacking monitoring for behaviors and side effects. The MDS Coordinator acknowledged these deficiencies.
A facility failed to promptly notify a physician and administer medication to a resident with abnormal lab results, resulting in a seven-day delay. Additionally, the facility did not accurately document the condition of another resident with a skin condition, despite physician's orders for wound care. The deficiencies were due to a lack of communication, documentation, and adherence to facility policies.
A resident with Type 2 diabetes and mobility issues did not receive adequate care to prevent skin integrity problems. The facility failed to document necessary interventions like turning and repositioning, and staff interviews revealed inconsistencies in care protocols and documentation. The lack of proper documentation and communication contributed to the deficiency.
The facility failed to monitor side effects and behaviors for residents on medications. A resident with nervous system disorder and agitation was not monitored for side effects until later, despite receiving medication. Another resident with heart failure had no interventions to monitor medication side effects, as the facility did not follow a protocol for such monitoring. A third resident on antipsychotic medication was not monitored for adverse reactions, with the DON acknowledging the lack of documentation.
A CNA failed to wear a protective gown while performing peri-care on a resident with a biliary drain, despite the facility's infection control policies requiring enhanced barrier precautions. Another CNA intervened by providing the gown, and the DON confirmed the need for proper PPE use.
A facility failed to maintain compliance with NFPA 101 standards as a main lobby door with a 15-second delayed egress lock was missing required signage. This was observed during a facility tour with the Maintenance Director, who acknowledged the deficiency.
The facility did not maintain documentation for the required five-year internal backflow preventer inspection of their Automatic Fire Sprinkler System (AFSS), as observed during a record review with the Maintenance Director. The absence of this documentation was acknowledged by the Maintenance Director during the inspection.
The facility failed to maintain and test their Essential Electrical System as per NFPA 99 standards, with no documentation available for the monthly generator conductance test. The Maintenance Director acknowledged the findings during a record review, indicating a lapse in required maintenance procedures.
Failure to Obtain and Document Timely Admission Physician Orders and Pain Management
Penalty
Summary
The facility failed to obtain and document timely physician orders for immediate care upon the admission of a resident who had recently undergone major spinal surgery and had complex medical needs, including a surgical site with staples and a Foley catheter. Despite the resident's transfer from the hospital with clear medication orders for pain management and other routine medications, the facility did not enter these orders into their system or administer the medications until the day after admission. There was no evidence that the facility contacted the physician to obtain necessary orders for pain medication, surgical site care, or Foley catheter care at the time of admission. The resident was admitted in the evening, alert and oriented, but dependent for all activities of daily living and with a history of metastatic cancer and recent surgery. Family members reported that the resident experienced significant pain upon admission, and that pain medication was not provided despite their concerns and communication with facility staff. Nursing documentation and interviews confirmed that pain assessments were not completed as required by facility policy, and that no pain reassessment or documentation occurred during the initial shift. The nurse responsible for the admission acknowledged forgetting to contact the physician for orders and failing to reassess or document the resident's pain. Further review of the medical record showed that none of the resident's routine or as-needed medications, including those for pain, were administered until the following day. The facility's own policies required pain observation and documentation at admission and when pain status changed, but these steps were not followed. Interviews with staff and the DON confirmed that the expected process was not carried out, resulting in a lack of timely physician orders and medication administration for the resident's immediate care needs.
Deficiencies in Medication Administration, Skin Care, and Nutritional Support
Penalty
Summary
The facility failed to provide adequate and appropriate health care to its residents, as evidenced by several deficiencies. One significant issue involved a resident who did not receive timely notification and administration of medication following abnormal lab results. The resident's lab results were reported to the facility, but there was a delay of approximately one week before the medication was administered. The facility's process for handling abnormal lab results was not followed, as there was no documentation of the physician being notified promptly, and the medication order was not entered into the system in a timely manner. Another deficiency was observed in the care of a resident with a skin condition. The facility failed to accurately document and assess the status and condition of the resident's skin. Observations revealed exposed and uncovered areas on the resident's skin, but there was no mention of these in the nursing progress notes. The facility's documentation did not reflect the current status or condition of the resident's skin, and there was no specific care plan in place for the resident's surgical site. Additionally, the facility did not ensure proper nutritional assessments and interventions for a resident, resulting in significant weight loss. The resident experienced a severe weight loss over several months, and the facility's documentation and monitoring of the resident's nutritional intake were inadequate. The resident's daughter expressed concern about the weight loss and the lack of communication regarding her mother's dietary preferences and needs. The facility's failure to follow physician's orders for nutritional support further contributed to the resident's decline in health.
Plan Of Correction
Resident #16 received ordered completed on with no adverse effects. Resident #2 surgical site was dressed and documented on with suture removal. Audit of residents with surgical sites for documentation and care plan development and implementation. Audit of residents with current orders for completion of physician notification and prompt start of if indicated. 100% Inservice for all licensed nurses on results with prompt physician notification and prompt start of ordered treatment. 100% Inservice for all licensed nurses for documentation of surgical sites and care plan development and implementation for surgical sites. DON or designee to audit weekly for results to physician with prompt start of ordered treatment and surgical site documentation with care plan development and implementation. DON or designee to report findings of all audits to QAPI committee meeting monthly. Resident #37 care plan updated for maintenance and prevention. 100% audit of residents with, for development and implementation of care plans as identified. 100% Inservice of all licensed nursing staff for care plan development and implementation for. DON or designee to audit residents with for care plan development and implementation weekly for 30 days and monthly ongoing. DON or designee to report findings of care plan audits to QAPI committee meeting monthly. Resident #51 was sent to hospital on as of. Resident #51 remains in hospital. Resident #167 and #169 orders for feeding were clarified and corrected on. 100% audit of all feeding residents for orders to meet nutritional needs, one order and RD documentation. Inservice DON and Registered Dietician of documentation and feeding order requirements. DON or designee to audit for feeding orders and RD documentation with feeds weekly times 4 weeks and then monthly ongoing. DON or designee to report findings of audits to QAPI committee meeting monthly.
Nutritional Deficiencies Due to Inadequate Monitoring and Feeding Regimen
Penalty
Summary
The facility failed to provide timely nutritional assessments and interventions, resulting in significant weight loss for a resident. The resident experienced a severe weight loss of 25.2% over eight months, with various dietary orders being inconsistently applied or discontinued without adequate follow-up. The resident's nutritional needs were not met, and there was a lack of consistent monitoring and adjustment of feeding regimens. Observations revealed that the resident's food intake was often inaccurately recorded, and the resident's preferences and dislikes were not adequately addressed, contributing to the nutritional deficiency. Another resident had overlapping orders for enteral feeding, leading to confusion and improper administration of nutritional support. The resident's feeding regimen was not consistently followed, with discrepancies in the amount of formula administered. The facility's staff failed to recognize and correct these issues, resulting in inadequate nutritional support for the resident. A third resident also experienced issues with enteral feeding, with observations showing that the prescribed feeding regimen was not followed. The resident's nutritional assessment indicated a risk for malnutrition, yet the recommended adjustments to the feeding regimen were not implemented. The facility's failure to adhere to physician orders and properly monitor and adjust feeding regimens contributed to the nutritional deficiencies observed in these residents.
Plan Of Correction
Resident #51 was sent to hospital on Resident #51 remains in hospital as of Resident #167 and #169 orders for feeding were clarified and corrected on 100% audit of all feeding residents for orders to meet nutritional needs, one order and RD documentation. Inservice DON and Registered Dietician of documentation and feeding order requirements. DON or designee to audit for feeding orders and RD documentation with feeds weekly times 4 weeks and then monthly ongoing. DON or designee to report findings of audits to QAPI committee meeting monthly.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in their care. For one resident, the care plan was not updated to reflect the resolution of a skin condition, and there were no interventions in place to prevent the development of new skin issues. The resident had a history of immobility and skin conditions, but the care plan did not include necessary updates or preventive measures. The MDS Coordinator acknowledged the oversight and stated that care plans should be updated within a couple of days when new issues arise. For another resident, the facility did not have a care plan in place for medications prescribed for agitation and restlessness. The resident had multiple medication orders, but there were no interventions documented to monitor for behaviors or side effects. The MDS Coordinator confirmed that a care plan should have been in place for the medications, including monitoring for potential side effects. This lack of a comprehensive care plan for medication management was identified as a deficiency during the survey.
Plan Of Correction
Resident #37 care plan updated for maintenance and prevention and Resident #59 care plan developed and implemented for medications. 100% audit of residents with medications and for development and implementation of care plans as identified. 100% Inservice of all licensed nursing staff for care plan development and implementation for medications. DON or designee to audit residents on medications and for care plan development and implementation weekly for 30 days and monthly ongoing. DON or designee to report findings of care plan audits to QAPI committee meeting monthly.
Deficiencies in Facility Environment and Maintenance
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several observations made during a survey. In six of the 27 resident rooms observed, issues were noted such as unsmooth and peeling paint on walls, dust and debris covering standing fans and A/C vents, and uncovered fluorescent bulbs in entryways. Additionally, some rooms had missing light bulbs, unpainted plaster on bathroom walls, and leaky faucets in bathroom sinks. Further observations revealed that call light pull cords were improperly wrapped around grab bars in bathrooms, which could potentially hinder their use. These deficiencies were acknowledged by the Director of Maintenance, who had been at the facility for 1.5 weeks, and the Administrator, who had started the week of the survey. Both acknowledged the findings during a side-by-side tour of the facility with the surveyors.
Plan Of Correction
Light bulbs replaced in Light covers replaced in and 24, 33 Standing fan cleaned in Walls smoothed and painted in Leaking faucet fixed in , and Call light pull cord removed from grab bar in Resident room environmental rounds completed by Administrator and Maintenance Director. Inservice Administrator and Maintenance Director on preventative maintenance rounds and correcting maintenance concerns. Administrator or designee to perform resident room environmental rounds weekly for 30 days, and monthly ongoing. Administrator or designee to report findings of environmental rounds to QAPI committee meeting monthly.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a deficiency in accommodating resident needs and preferences. Resident #10 was observed multiple times with the call light draped behind the bed and out of reach. Despite being able to use the call bell, the resident could not reach it and had to resort to yelling for assistance. Interviews with staff confirmed that call lights are supposed to be within reach of residents at all times, yet this was not the case for Resident #10. Similarly, Resident #2 was observed banging on her overbed table and yelling for help because she needed to go to the bathroom. The call light was clipped to the top corner of her pillow, making it inaccessible. When a CNA entered the room, she found the call light hanging off the bed and handed it to the resident, who then used it to call for assistance. The resident's inability to reach the call light led to her distress and need for immediate help.
Plan Of Correction
Call lights for resident #2 and #10 were placed within reach of the residents. Audit of 100% of residents that their call lights were in reach. Educate 100% of staff to place call lights within reach of residents. Call light observation audits to be performed by DON or designee 5 times per week for 30 days, and then monthly ongoing. DON or designee to report findings of call light observation audits to QAΡΙ committee meeting monthly.
Deficiencies in Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed in 6 out of 27 resident rooms. Observations included unsmooth and peeling paint on the wall behind a bed, a standing fan covered with dust and debris, and uncovered fluorescent bulbs in entryways. Additionally, there were issues with cleanliness and maintenance, such as A/C vents covered with dust and debris, a lightbulb out in a bathroom, unpainted plaster on a bathroom wall, and leaky faucets in bathroom sinks. Further observations revealed a missing light bulb in an entryway and a call light pull cord wrapped around a grab bar in a bathroom. These deficiencies were acknowledged by the Director of Maintenance, who had been at the facility for 1.5 weeks, and the Administrator, who started the week of the survey. The report highlights the facility's failure to maintain a sanitary, orderly, and comfortable environment, as required by the regulations.
Plan Of Correction
F584/N110 Light bulbs replaced in Light covers replaced in Standing fan cleaned in 24, 33 Walls smoothed and painted in Leaking faucet fixed in Call light pull cord removed from grab bar in Resident room environmental rounds completed by Administrator and Maintenance Director. Inservice Administrator and Maintenance Director on preventative maintenance rounds and correcting maintenance concerns. Administrator or designee to perform resident room environmental rounds weekly for 30 days, and monthly ongoing. Administrator or designee to report findings of environmental rounds to QAPI committee meeting monthly.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in their care. Resident #37 was admitted with diagnoses including Type 2 diabetes and unspecified abnormalities of gait and mobility. The care plan for this resident was not updated to reflect the resolution of a skin condition, and there were no interventions in place to prevent the development of new skin issues. The MDS Coordinator acknowledged that the care plan should have been updated and resolved earlier. Resident #59, who was admitted with degenerative nervous system issues and restlessness, had no care plan in place for medications prescribed for agitation and restlessness. The MDS Coordinator confirmed that there should have been a care plan to monitor for behaviors and side effects related to these medications. The lack of a care plan for medication management was acknowledged as a deficiency by the MDS Coordinator. Interviews with the MDS Coordinator revealed that care plans should be updated within a couple of days when new issues arise, and that there should be interventions in place for residents with a history of skin issues. The failure to update and implement comprehensive care plans for these residents indicates a lapse in the facility's adherence to regulatory requirements for person-centered care planning.
Plan Of Correction
Resident #37 care plan updated for maintenance and prevention and Resident #59 care plan developed and implemented for medications. 100% audit of residents with medications and for development and implementation of care plans as identified. 100% Inservice of all licensed nursing staff for care plan development and implementation for medications. DON or designee to audit residents on medications and for care plan development and implementation weekly for 30 days and monthly ongoing. DON or designee to report findings of care plan audits to QAPI committee meeting monthly.
Failure to Notify Physician and Document Resident Care
Penalty
Summary
The facility failed to promptly notify the ordering physician and administer medication to a resident with abnormal lab results. Resident #16, who was re-admitted with diagnoses including Type 2 diabetes with complications, experienced a delay in receiving oral medication. The lab results indicating an abnormal culture were reported to the facility, but the medication was not administered until seven days later. The delay was due to a lack of documentation and communication among the nursing staff, as well as the absence of a tracking system for abnormal lab results. Additionally, the facility failed to accurately document and assess the status and condition of a resident with a skin condition. Resident #2, who had a severe cognitive impairment, was observed with exposed and uncovered areas on her left lower extremity. Despite the presence of physician's orders for wound care, there was no documentation of the existence, presence, or condition of the resident's wounds in the nursing progress notes. The lack of documentation and assessment of the resident's skin condition was acknowledged by the Director of Nursing. The deficiencies highlight the facility's failure to adhere to its policies and procedures for communicating urgent lab results and documenting resident care. The absence of a care plan for Resident #16's medication and Resident #2's wound care further contributed to the deficiencies. The Director of Nursing acknowledged the need for prompt notification of physicians and detailed documentation of residents' conditions.
Plan Of Correction
Resident #16 received ordered completed on with no adverse effects. Resident #2 surgical site was dressed and documented on with suture removal. Audit of residents with surgical sites for documentation and care plan development and implementation. Audit of residents with current orders for completion of physician notification and prompt start of indicated treatment. 100% Inservice for all licensed nurses on results with prompt physician notification and prompt start of ordered treatment. 100% Inservice for all licensed nurses for documentation of surgical sites and care plan development and implementation for surgical sites. DON or designee to audit weekly for prompt notification of results to physician with prompt start of ordered treatment and surgical site documentation with care plan development and implementation. DON or designee to report findings of all audits to QAPI committee meeting monthly.
Failure to Prevent Skin Integrity Issues
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards to prevent skin integrity issues. Resident #37, who was admitted with diagnoses including Type 2 diabetes and unspecified abnormalities of gait and mobility, was not provided with adequate care to prevent the development of skin conditions. The resident's records showed a lack of documentation for turning and repositioning, which are critical interventions for preventing skin breakdown. The Treatment Administration Record for the month in question did not document the care provided, and the Care Plan did not include measures for skin condition prevention. Interviews with facility staff revealed inconsistencies in the documentation and execution of care protocols. The Assistant Director of Nursing acknowledged that weekly skin checks were not performed as ordered, and there was no documentation of care being performed as required. Additionally, the Certified Nursing Assistant and Registered Nurse indicated that there was no designated place in the electronic medical record to document turning and repositioning. The Director of Nursing and an Advanced Registered Nurse Practitioner provided conflicting information about the resident's skin condition, further highlighting the lack of proper documentation and communication within the facility.
Plan Of Correction
Resident #37 orders updated for turning and repositioning every 2 hours as tolerated to allow for CNA documentation and care plan developed and implemented for 100% audit with, for turning and repositioning documentation and care plan development and implementation. Inservice 100% of licensed nurses on turning and repositioning order entry for CNA documentation and care plan development and implementation for DON or designee to audit orders for turning and repositioning to allow documentation by CNAs and care plan development and implementation for 2 times weekly for 30 days, and then monthly ongoing. DON or designee to report findings of audits to QAPI committee meeting monthly.
Failure to Monitor Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to ensure adequate monitoring of side effects and behaviors for residents receiving medications, as evidenced by the cases of three residents. Resident #59 was admitted with diagnoses including degenerative nervous system disorder and agitation. Despite being prescribed medications for agitation and restlessness, there was no order to monitor side effects or behaviors until a later date. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed that the resident received the medication as ordered, but there was no documentation of behavior or side effect monitoring until a specified date. Additionally, the care plan for Resident #59 lacked interventions to monitor for behaviors or side effects related to the medications. Resident #1, who was admitted with a diagnosis of acute diastolic heart failure and other conditions, had a care plan indicating a need for monitoring potential changes in behavior and side effects due to medication use. However, the facility failed to implement interventions to monitor these changes. The Director of Nursing (DON) stated that monitoring behaviors or side effects for these medications was not part of the protocol followed by the facility. Resident #45, admitted with a diagnosis of moderate cognitive impairment, was prescribed an antipsychotic medication. The care plan indicated the need to monitor for adverse reactions, but the MAR and TAR did not show that the facility was monitoring the side effects and adverse reactions of the medication. The DON acknowledged that there should be an order to monitor side effects, and a registered nurse confirmed that the monitoring was not documented in the electronic system.
Plan Of Correction
Resident #45 had orders clarified for monitoring of side effects of medications. Resident #1 and #59 had orders clarified for monitoring of side effects and behaviors for medications. Audit of 100% of residents with medications for side effect monitoring. Inservice all licensed nursing staff on orders to have side effect monitoring and orders with medications to have side effect and behavior monitoring. DON or designee to audit for side effect monitoring and medications for side effect and behavior monitoring weekly for 4 weeks and then monthly ongoing. DON or designee to report findings of audits to QAPI committee meeting monthly.
Inadequate Use of PPE During Resident Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control program during a high-contact resident care activity. Specifically, a Certified Nursing Assistant (CNA), identified as Staff N, was observed performing peri-care on a resident without wearing the appropriate personal protective equipment (PPE), specifically a protective gown. This occurred despite the resident having a biliary drain in place, which necessitated enhanced barrier precautions. The CNA was only wearing gloves and was in close proximity to the resident's exposed peri-area when another staff member, Staff O, intervened by handing a protective gown through the door. The deficiency was further highlighted during interviews with the staff involved. Staff N was unable to provide a clear explanation for not donning the gown before starting the care procedure. Staff O acknowledged noticing the lack of PPE and acted by providing the gown. The Director of Nursing (DON), who also serves as the Infection Control Nurse, confirmed that the CNA should have worn the gown and mentioned that recent education on infection control procedures, including the use of PPE, had been provided to the nursing staff. The incident was documented with photographic evidence.
Plan Of Correction
Care was provided to resident #171 after a gown was provided to staff N by staff O inservice to nursing staff regarding Enhanced Barrier Precautions and donning gowns prior to care. DON or designee to do observational audits for Enhanced Barrier Precautions with gown donning prior to care 5 times weekly for 30 days and then monthly ongoing. DON or designee to report findings of audits to QAPI committee meeting monthly.
Missing Signage on Delayed Egress Door
Penalty
Summary
The facility failed to maintain egress doors equipped with delayed egress locking arrangements in accordance with NFPA 101 standards. During a facility tour conducted on April 8, 2025, between 1:30 PM and 2:45 PM, it was observed that the main lobby door, which was equipped with a 15-second delayed egress lock, was missing the required signage. This observation was made in the presence of the Maintenance Director, who acknowledged the findings. The deficiency was further discussed with the Maintenance Director during an exit conference held on the same day at 3:00 PM. The lack of required signage on the egress door represents a failure to comply with the NFPA 101 (2021 Edition) 7.2.1.6.1.1(4)(a) standards, which mandate specific requirements for delayed egress locking systems to ensure safety and compliance.
Plan Of Correction
ACTIONS TAKEN TO CORRECT THE DEFICIENCY: All doors will be monitored on a monthly basis to ensure all 15 second signs are posted on the main entry exit egress exit door. HOW OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE WILL BE IDENTIFIED: A Full audit will be completed for all for all residents to ensure that all residents are provided a safe environment. MEASURES PUT INTO PLACE TO ENSURE THE SAME DEFICIENT PRACTICE DOES NOT REOCCUR: Audits will be completed on a monthly basis to ensure the same deficient practice does not re occur. HOW THE CORRECTIVE ACTION WILL BE MONITORED: All audits will be brought to QAPI monthly thereafter.
Failure to Document Five-Year Sprinkler System Inspection
Penalty
Summary
The facility failed to maintain their Automatic Fire Sprinkler System (AFSS) in accordance with NFPA 101 standards. During an inspection on April 8, 2025, it was observed that there was no documentation available for the required five-year internal backflow preventer inspection. This deficiency was identified during a record review conducted with the Maintenance Director, who acknowledged the findings. The lack of documentation for the inspection was discussed with the Maintenance Director during the exit conference on the same day.
Plan Of Correction
NFPA 101 ACTION(S) TAKEN TO CORRECT THE DEFICIENCY: The facility scheduled a 5-year sprinkler backflow on 4/16/2025 and completed on 4/17/2025. HOW OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE WILL BE IDENTIFIED: A full audit was completed to identify all residents with potential to be affected by the deficient practice. The potential for harm was minimal. MEASURES PUT INTO PLACE TO ENSURE THE SAME DEFICIENT PRACTICE DOES NOT REOCCUR: The Maintenance Director or Designee will conduct an audit on an annual basis to ensure the 5-year sprinkler backflow is in compliance. HOW THE CORRECTIVE ACTION WILL BE MONITORED: The Maintenance Director will audit compliance with the 5-year sprinkler back annually for compliance. Findings will be brought to QAPI.
Failure to Document Monthly Generator Conductance Test
Penalty
Summary
The facility failed to maintain and test their Essential Electrical System (EES) in accordance with NFPA 99 standards. During a record review conducted on April 8, 2025, between 10:00 AM and 1:30 PM, it was found that there was no documentation available for the monthly generator conductance test. This deficiency was identified for 1 of 1 monthly generator conductance test, indicating a lapse in the required maintenance and testing procedures. The Maintenance Director was present during the record review and acknowledged the findings. The absence of documentation for the generator conductance test suggests that the facility did not perform or properly record the necessary monthly test to ensure the generator's capability to supply service within the required 10 seconds. This oversight was discussed with the Maintenance Director during the exit conference on the same day.
Plan Of Correction
CFR(s) NFPA 110, 99 ACTION(S) TAKEN TO CORRECT THE DEFICIENCY: Maintenance Director conducted a test on 4/8/2025, 4/16/2025, & 4/21/2025 to ensure the battery conductance test is at the correct voltage and by IPS TAW Generator Company on 4/21/2025. HOW OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE WILL BE IDENTIFIED: The facility conduct a full house audit to identify all residents with the potential to be affected. The potential for harm is minimum. MEASURES PUT INTO PLACE TO ENSURE THE SAME DEFICIENT PRACTICE DOES NOT RECUR: The Maintenance Director will complete the Generator Conductance test on a monthly basis. Findings and the conductance test log will be brought to QAPI for 6 months and then annually thereafter. HOW THE CORRECTIVE ACTION WILL BE MONITORED: All findings will be brought to QAPI for six months and Annually thereafter.
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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