Groves Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Wales, Florida.
- Location
- 512 S 11th St, Lake Wales, Florida 33853
- CMS Provider Number
- 105269
- Inspections on file
- 27
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Groves Center during CMS and state inspections, most recent first.
Two residents with indwelling catheters did not receive necessary care to prevent or manage UTIs, including failure to follow physician orders for catheter changes, missed laboratory testing, and incomplete antibiotic administration. One resident developed a severe infection that progressed to Fournier's gangrene and sepsis, while another did not receive the full prescribed course of antibiotics, with no documentation or provider notification regarding the missed doses. Staff interviews revealed inconsistent training and documentation practices related to catheter care and change of condition.
The facility failed to follow physician orders for catheter care and lab monitoring, resulting in a resident developing a severe UTI that progressed to Fournier's gangrene and sepsis. Another resident did not receive the full course of prescribed antibiotics for a UTI, with no documentation of provider notification. Two residents with abnormal lab results did not have timely provider notification or documentation, and another resident experienced unmanaged pain for two days despite documented high pain levels and available orders for pain medication.
A resident with multiple medical conditions reported missing personal items, including a blanket and clothing. Despite repeated complaints to various staff members and a search of the laundry room, not all items were recovered and no formal grievance was filed or investigated, contrary to facility policy.
A resident with complex medical needs experienced a significant change in condition, including lethargy and pain, and received late medication administration. The resident's representative reported concerns to staff and the NHA, explicitly alleging neglect, but the incident was not reported or investigated as required by facility policy. Staff interviews confirmed the assigned LPN was absent from the unit for extended periods, and there was no documentation of provider notification or change of condition assessment.
The facility did not conduct a thorough investigation into an allegation of neglect involving a resident with a foley catheter. The NHA failed to contact the family, did not interview all relevant staff, and did not obtain necessary medical records or consult the resident's urologist. Key clinical details, such as the resident's pain complaints and the presence of wounds, were missed or unknown to the investigation team.
The facility did not ensure proper catheter care for several residents, including failure to change catheter bags as ordered, lack of securement devices for catheters, and inconsistent response to signs of infection such as cloudy lines and sediment. Staff interviews confirmed that securement devices were not used despite facility policy and best practice guidelines, and one resident developed a pressure injury at the catheter site due to lack of stabilization.
A resident with a colostomy and abdominal wounds experienced unmanaged pain for several days after admission, despite having orders for acetaminophen and Percocet. Nursing staff documented significant pain but did not administer the prescribed medications or notify a physician, and there was no documentation explaining the delay. Facility policy required prompt pain management, but these procedures were not followed, resulting in the resident's pain going untreated.
Two residents with complex medical conditions had abnormal lab results that were not communicated to their providers as required. In both cases, there was no documentation that the LPN or nursing staff notified the provider of the abnormal findings, despite facility policy and expectations for prompt notification and documentation. The DON and Regional Nurse Consultant confirmed the lack of documentation and acknowledged discrepancies in physician notifications.
Surveyors found that multiple residents did not receive timely incontinence care, with staff failing to respond promptly to call lights and leaving residents in soiled briefs for extended periods, particularly during night shifts. Residents with significant medical and functional needs were affected, and care plans requiring regular checks were not consistently followed, as confirmed by both resident interviews and care documentation.
Surveyors found that the facility did not ensure PPE was available or used for residents on Contact Precautions or Enhanced Barrier Precautions. Multiple rooms with posted precaution signs lacked accessible PPE, and staff entered rooms without donning required protective equipment. Staff interviews revealed confusion about isolation requirements and inconsistent application of infection control protocols for residents with MDROs, wounds, and IV access.
Surveyors observed live insects in multiple facility areas, including the dining and activity halls, and a resident reported persistent roaches in their room despite cleaning and spraying. Facility records showed ongoing pest control treatments for various pests, but interviews with the DOM and NHA revealed a lack of awareness and inconsistent responses to pest complaints, indicating the pest control program was not effective.
A grievance filed by a resident's family about missing dentures was not promptly or thoroughly addressed, with gaps in documentation, communication, and follow-up. The facility did not assign responsibility for the grievance, failed to document a resolution or satisfaction of the complainant, and did not maintain adequate records of communication, contrary to its own grievance policy.
A resident with chronic pain conditions did not receive a scheduled dose of Oxycodone because the medication supply ran out and was not reordered in time. Staff interviews revealed confusion about the process for obtaining narcotics from the automated dispensing machine and inconsistent communication with the pharmacy, resulting in a delay in medication delivery and a missed dose.
Several residents experienced significant delays and omissions in incontinence care, with reports of long wait times for assistance, incomplete documentation, and staff shortages leading to residents remaining in soiled briefs for extended periods. Staff interviews confirmed heavy workloads and insufficient staffing contributed to the failure to provide timely care as required by care plans and facility policy.
A facility failed to protect resident privacy and confidentiality when an RN disposed of used feeding bottles with identifiable information in an unsecured trash can and left a medication cart unattended with resident information exposed. The DON confirmed that staff should have marked off identifiable information before disposal.
Two residents with tracheostomies in a facility experienced deficiencies in care due to unconfirmed physician orders and lack of documentation for essential care activities. One resident, with severe cognitive impairment, had missing documentation for tracheostomy suctioning, medication administration, and vital sign monitoring. Another resident, cognitively intact, also faced similar issues with tracheostomy management and enteral feeding. The Director of Nursing confirmed the documentation gaps, which were against the facility's policies.
A resident with a tracheostomy did not receive care consistent with professional standards at an LTC facility. An RN failed to follow enhanced barrier precautions, including wearing a gown and performing proper hand hygiene, while providing care. The resident had a complex medical history and required specific care protocols, which were not followed, leading to a deficiency in care.
A facility failed to follow standard and enhanced barrier precautions during the care of two residents, leading to a deficiency in infection prevention and control. A registered nurse (RN) did not wear a gown or perform proper hand hygiene while providing care to a resident with a tracheostomy and gastrostomy tube, despite the requirement for enhanced barrier precautions. The facility's policies and the resident's care plan required the use of gloves and gowns during high-contact care activities, which the RN did not comply with.
Failure to Prevent and Manage UTIs in Residents with Indwelling Catheters
Penalty
Summary
The facility failed to provide necessary care and services to prevent urinary tract infections (UTIs) from developing or worsening in two residents with indwelling catheters. For one resident, the facility did not follow physician orders for a silver coated Foley catheter, failed to order and perform required laboratory tests, and did not change the catheter according to the prescribed schedule. The resident's medical records showed missed documentation of a urology appointment, lack of evidence that the ordered silver coated catheter was ever provided, and a significant gap between catheter changes. The resident experienced escalating pain, with pain levels documented as high as 10 out of 10, and there was a lack of timely assessment and documentation of vital signs and laboratory testing during a period of worsening symptoms. The resident ultimately developed a severe UTI that progressed to Fournier's gangrene and sepsis, as confirmed by hospital records, which also noted the resident had been requesting to be sent to the emergency room for several weeks prior to transfer. In the second case, another resident with a history of chronic health conditions and an indwelling catheter was prescribed a five-day course of Ertapenem for a UTI. The medication administration records showed that only three out of five doses were given, with no documentation explaining the missed doses or indicating that the provider was notified about the incomplete antibiotic course. There was also no evidence in the progress notes to account for the missed doses or any follow-up actions taken in response to the incomplete treatment. Interviews with staff revealed inconsistencies in knowledge and practice regarding catheter care, change of condition, and documentation. Some staff reported receiving only occasional in-service training, and there was a lack of demonstration-based education. Facility policies required staff to notify providers of abnormal findings and to document all relevant communications and follow-up actions, but these procedures were not consistently followed. The facility's own abuse prevention policy defined neglect as the failure to provide necessary goods and services to avoid physical harm, pain, or distress, which was reflected in the findings for both residents.
Failure to Provide Necessary Care, Timely Provider Notification, and Pain Management
Penalty
Summary
The facility failed to provide necessary care and services as ordered and according to residents' preferences and goals, resulting in multiple deficiencies. For one resident with a history of neurogenic bladder and recurrent UTIs, the facility did not follow physician orders for a silver-coated Foley catheter, failed to change the catheter as scheduled, and did not order or document required laboratory tests to monitor for infection. The resident experienced escalating pain, which was documented but not adequately addressed, and there was a lack of timely provider notification regarding abnormal findings. Ultimately, the resident developed a severe UTI that progressed to Fournier's gangrene and sepsis, with hospital records indicating the resident had been requesting to go to the emergency room for weeks due to feeling unwell and experiencing foul-smelling drainage. Another resident with a UTI did not receive the full course of prescribed antibiotics, with only three out of five doses administered. There was no documentation explaining the missed doses or indicating that the provider was notified of the incomplete antibiotic therapy. This lapse in care placed the resident at risk for worsening infection or delayed recovery. Additionally, the facility failed to ensure that providers were notified of abnormal laboratory results for two other residents. In both cases, there was no documentation that the physician was informed of critical lab values, despite facility policy requiring prompt notification and documentation of such events. The facility also failed to manage pain appropriately for another resident who reported significant pain upon admission. Despite documented pain levels of 6 out of 10 and orders for pain medication, the resident did not receive any pain medication for two days, and there was no documentation of provider notification or explanation for the delay. Interviews with staff confirmed that pain of this severity should have prompted provider contact and administration of ordered medications. Facility policies reviewed emphasized the importance of timely pain management, provider notification, and documentation, all of which were not followed in these cases.
Failure to File and Investigate Grievance for Missing Resident Items
Penalty
Summary
The facility failed to ensure that a grievance was filed, investigated, and resolved for a resident who reported missing personal items. The resident, who was admitted with diagnoses including muscle wasting, atrophy, MRSA infection, and osteomyelitis, reported missing a blanket and several blouses. The resident and a family member searched the laundry room for the missing items, but not all items were recovered. Despite the resident's repeated complaints and the involvement of multiple staff members, including the Admissions Director and Housekeeping Director, no formal grievance was filed regarding the missing items. Interviews with staff revealed a lack of clarity and communication regarding the grievance process. The Social Services Director was unaware of the missing items and confirmed that no grievance had been logged. The Admissions Director and Housekeeping Director both acknowledged the resident's complaints but did not initiate the grievance process, assuming the issue was being addressed informally. The facility's policy requires staff to assist residents in filing grievances and to document and investigate concerns, but this procedure was not followed in this case.
Failure to Report and Investigate Alleged Neglect Following Change in Resident Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely reporting and investigation of an allegation of neglect for one resident. The resident's representative reported concerns to staff regarding the resident's lethargy, pain, and delayed medication administration. The representative was unable to locate the assigned nurse for over an hour, and when the nurse was found, she was dismissive of the concerns. The representative explicitly told the Nursing Home Administrator (NHA) that he believed the resident was neglected, but did not receive any follow-up from the facility. Medical record review revealed that the resident, who had a complex medical history including end-stage renal disease, lupus, and chronic kidney disease, experienced a change in condition with increased lethargy and pain. Despite these changes and abnormal laboratory results, there was no documentation that a change of condition assessment was completed or that a provider was notified. Medications were administered late throughout the day, and staff interviews confirmed that the nurse assigned to the resident was repeatedly absent from the unit for extended periods without proper coverage. The facility's own policy required immediate reporting and investigation of alleged neglect, but the incident was not documented in the facility's reportable log, and there was no evidence that the required notifications or investigations were completed. Interviews with the DON and Regional Nurse Consultant confirmed that the expected procedures for assessment and provider notification were not followed. The NHA acknowledged that the nurse's actions could constitute neglect but did not ensure the incident was reported as required.
Failure to Conduct Thorough Investigation of Neglect Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident with a foley catheter. The Nursing Home Administrator (NHA) became aware of the allegation when a Department of Children and Families (DCF) agent arrived and reported that the resident's family alleged the facility did not replace the resident's foley catheter or provide catheter care, which they believed led to an infection. The NHA did not contact the family for further information and was unsure about the details of the catheter order. The investigation did not include contacting the resident's urologist, and the NHA was unaware of the resident's complaints of severe pain that began several days before the resident was sent to the emergency room. The NHA stated that interviews were conducted with some staff, but could not provide records of these interviews, and did not interview all relevant staff involved in the resident's care. Additionally, the facility did not obtain hospital records related to the resident's care, citing difficulty in obtaining them, and was unaware of the presence of a perineal wound and an unstageable pressure injury where the foley catheter would lay. The Senior Regional Nurse Consultant (SRNC) was the only attendee aware of the hospital report indicating gangrene. The facility's own policy required a complete and thorough investigation, including interviews with all relevant parties and review of documentation, but these steps were not fully completed in this case.
Failure to Provide Proper Catheter Care and Securement
Penalty
Summary
The facility failed to provide proper catheter care for four residents, as evidenced by observations, interviews, and record reviews. Catheter drainage bags were not changed according to physician orders, with some bags dated well beyond recommended intervals. Multiple residents were observed with catheters lacking adhesive or stabilization devices, despite facility policy requiring securement to prevent movement and urethral traction. Cloudy catheter lines and sediment were noted, and staff responses to these findings were inconsistent, with some staff indicating irrigation or culture requests, but not adhering to established protocols. One resident had a pressure injury corresponding to the location of an unsecured catheter, and the Director of Nursing confirmed that securement devices were not in use, contrary to both facility policy and best practice guidelines. Staff interviews revealed that while in-service training on catheter care had occurred recently, there was no consistent application of securement practices, and demonstration training had not yet started. The facility's own policy and external best practice guidelines both emphasize the importance of securing catheters to prevent complications, but this was not implemented. Residents with a history of frequent UTIs and catheter-related wounds were not receiving care in accordance with these standards, as evidenced by the lack of securement and timely bag changes.
Failure to Provide Timely Pain Management for Resident with Colostomy
Penalty
Summary
A deficiency occurred when a resident with a history of Crohn's disease, abdominal wounds, and a colostomy experienced unmanaged pain upon admission. The resident reported that it took several days to receive pain medication, during which time her pain increased, especially when her colostomy bag broke and her skin became raw. The resident described the pain as severe, particularly during colostomy care and cleaning, and expressed distress over the delay in receiving pain relief. Review of the resident's records showed that pain was documented at a level of 6 out of 10, but neither acetaminophen nor Percocet, both of which were ordered, were administered on the days the pain was recorded. There was no documentation explaining why pain medication was not provided, nor any evidence that a physician was notified about the resident's pain levels during this period. Interviews with nursing staff and the DON confirmed that pain medication should have been administered and that a pain level of 6 warranted contacting the provider, but this did not occur. Facility policy required prompt assessment and management of pain, including obtaining physician orders and administering medication as needed. Despite these guidelines, the resident's pain was not addressed in a timely manner, and the care plan interventions to observe and manage pain were not followed. The lack of documentation and failure to provide ordered pain medication led to unmanaged pain for the resident.
Failure to Notify Providers of Abnormal Lab Results
Penalty
Summary
The facility failed to ensure that providers were notified of abnormal laboratory results for two out of three residents reviewed. In the first case, a resident with a complex medical history including end-stage renal disease, systemic lupus erythematosus, and chronic kidney disease experienced seizures and was noted by her representative to be lethargic, in pain, and not her usual self. Despite laboratory tests being ordered and drawn, the assigned LPN informed the resident's representative that results would be reviewed when the doctor returned and did not notify the provider of the abnormal findings, which included low iron, glucose, and chloride, as well as elevated BUN, creatinine, and potassium. There was no documentation in the progress notes that the physician was informed of these abnormal results, and the primary care provider confirmed he was not contacted regarding the resident's pain, change in condition, or lab values on that day. In the second case, another resident with end-stage renal disease, epilepsy, thrombocytopenia, and a history of transient ischemic attack had STAT labs ordered due to tremors and feeling cold. The labs, which revealed multiple abnormal values such as low RBC, hemoglobin, hematocrit, platelet count, and high neutrophils, were completed and available the same day. However, there was no documentation that the provider was notified of these abnormal STAT lab results. The provider's assistant stated that notification and documentation of such results would be expected, but neither she nor the provider recalled being notified, and the facility's records did not show evidence of such communication. Interviews with the DON and Regional Nurse Consultant confirmed that the facility's policy requires prompt notification and documentation of abnormal lab results, especially for STAT and critical values. They acknowledged discrepancies in physician notifications and verified that there was no documentation of provider notification for either resident prior to discharge. The facility's policy also specifies that such communications should be documented in the progress notes or on the lab results sheet, but this was not done in these cases.
Failure to Provide Timely Incontinence Care
Penalty
Summary
Surveyors identified that the facility failed to provide timely and appropriate incontinence care for four residents who were sampled. Multiple residents reported that staff did not respond promptly to call lights, especially during night shifts, resulting in residents remaining in soiled briefs for extended periods, sometimes until the next shift. In some cases, staff turned off call lights without providing care, and residents had to wait for significant periods, sometimes up to an hour and a half, before receiving assistance. These incidents were corroborated by resident interviews and review of care documentation, which showed missed incontinence care tasks across various shifts. The residents involved had significant medical histories and functional limitations. One resident had diagnoses including overactive bladder, muscle weakness, and required substantial assistance with toileting hygiene, being always incontinent for bowel and bladder. Another resident, with a history of femur fracture and diabetes, also required assistance and was always incontinent, but reported that staff response was slow, leading to prolonged periods in soiled briefs. A third resident, with severe cognitive impairment and hemiplegia, was dependent on staff for all toileting needs and was not a candidate for a toileting program, yet did not receive incontinence care as scheduled. A fourth resident, with a history of fracture and muscle atrophy, was occasionally incontinent and dependent on staff, but also experienced significant delays in care. Care plans for these residents specified the need for regular incontinence checks and care, including checking and changing upon arising, before and after meals, at bedtime, and as needed. Staff interviews revealed that CNAs relied on residents to use call lights to request care and checked on residents when time permitted, rather than following scheduled checks. The Director of Nursing acknowledged previous issues with night shift care and stated that residents should be checked every two hours, with documentation required for each shift. However, documentation and resident reports indicated that these protocols were not consistently followed, resulting in unmet care needs.
Failure to Provide PPE and Implement Isolation Precautions for Residents on Contact and Enhanced Barrier Precautions
Penalty
Summary
Surveyors observed that the facility failed to ensure appropriate implementation of infection prevention and control measures for residents requiring isolation precautions. Multiple observations revealed that personal protective equipment (PPE) was not available outside or near the rooms of residents on Contact Precautions or Enhanced Barrier Precautions (EBP). Staff were seen entering rooms with posted precaution signs without donning PPE, and PPE storage was inconsistent, with mesh bags inside rooms often found empty. Signs indicating the need for EBP or Contact Precautions were posted, but the required PPE was not accessible as per facility policy and CDC guidelines. Residents involved had significant medical histories, including bacteremia, MRSA, ESBL infections, wounds, and intravenous access, all of which necessitate strict adherence to isolation protocols. Orders and care plans for these residents specified the need for EBP and Contact Precautions, yet observations showed that these precautions were not consistently followed. Staff interviews revealed confusion regarding which residents required which type of precautions, and there was a lack of clarity about the correct placement and availability of PPE. Some staff were unaware of the specific organisms present or the correct isolation status of residents, leading to further lapses in infection control. The facility's own policy required gloves and gowns to be donned before entering rooms under Contact Precautions, and for PPE to be available for EBP during high-contact activities. However, surveyors found that in at least five rooms with posted precaution signs, PPE was not supplied as required. Interviews with the infection preventionist, DON, and other staff confirmed inconsistencies in the application of precautions and the stocking of PPE. The lack of PPE availability and staff adherence to protocols directly contributed to the deficiency in the facility's infection prevention and control program.
Ineffective Pest Control Program Resulting in Ongoing Insect Infestations
Penalty
Summary
Surveyors observed multiple live insects in various areas of the facility during two consecutive days of inspection. On the first day, a live insect was seen crawling near the conference room in the 400-hall, and small flying insects were observed landing on surfaces in the dining hall/activity area while residents were present. The following day, another live insect was seen crawling near the 100-hall, with staff present in the area. Additionally, a resident reported the presence of roaches in their room, stating that staff had been notified, drawers were cleaned, and spraying had occurred, but the issue persisted. Facility documentation, including pest control service inspection reports, confirmed ongoing treatments for flies, rats, ants, and roaches, with pest sightings documented. Interviews with the Director of Maintenance and the Nursing Home Administrator revealed that pest control services were contracted and provided weekly, with additional visits arranged for emergencies. However, the Director of Maintenance denied the presence of roaches, attributing sightings to a local Florida bug, and was unaware of any pest complaints. The facility's pest control policy requires maintaining contracts, service logs, and evaluating service effectiveness, but observations and resident reports indicated the pest control program was not effective in preventing or addressing infestations.
Failure to Promptly Address and Resolve Grievance Regarding Missing Dentures
Penalty
Summary
The facility failed to ensure that a grievance regarding a resident's missing bottom dentures was promptly addressed and resolved to the satisfaction of the complainant. The grievance was filed by the resident's family member, and the facility's Grievance/Concern Log indicated the concern was resolved within two days. However, documentation revealed that the facility did not designate a specific individual or department to handle the grievance, and there was no documented conclusion or summary of findings. The log also did not indicate whether the grievance was resolved to the satisfaction of the resident or their representative. Interviews with facility staff, including the Nursing Home Administrator (NHA), Risk Management Consultant (RMC), Business Office Manager (BOM), and Social Service Director (SSD), revealed inconsistencies and gaps in communication and documentation. The BOM reported only one documented contact with the family on the day the resident left the facility, and a follow-up attempt was made nearly two months later. The SSD was unaware of the grievance and confirmed there were no social service notes in the resident's record regarding the missing dentures or related conversations with the family. The facility's policy required prompt efforts to resolve grievances, assignment of concerns to appropriate departments, and documentation of resident or representative satisfaction, none of which were fully met in this case. The resident involved had multiple medical diagnoses, including a femur fracture, diabetes, alcohol abuse, and malnutrition, and was transferred to the emergency room and did not return to the facility. The admission inventory indicated the resident had both top and bottom dentures, but the form was undated. Progress notes did not document the representative's concern or any facility communication regarding the missing dentures. The lack of thorough investigation, documentation, and follow-up led to the failure to resolve the grievance in accordance with facility policy.
Failure to Provide Timely Pain Medication Due to Reordering and Communication Lapses
Penalty
Summary
The facility failed to provide pain medication as ordered for one resident, resulting in a missed dose of Oxycodone 10 mg for non-acute pain. The resident, who had a history of spinal stenosis, neuralgia, neuritis, monoarthritis, and unspecified pain, reported issues with receiving pain medication over the past month. Record review confirmed that the medication count for Oxycodone reached zero on 4/25/2025, and a dose was missed on 4/26/2025. The prescription for the medication was faxed to the pharmacy on the morning of 4/26/2025, but the medication was not delivered until after 7:30 p.m. that day. Interviews with nursing staff and pharmacy representatives revealed that the process for obtaining narcotics from the automated medication dispensing machine was not consistently followed, and there was confusion regarding when and how to access emergency supplies. Staff indicated that nurses are expected to reorder narcotics when the count reaches ten pills, and that a warning is present on the medication card to prompt reordering. However, the medication was not reordered in time, and the resident went without the prescribed pain medication. The facility's policy requires timely communication of orders to the pharmacy, but this process was not effectively implemented in this instance.
Failure to Provide Timely and Consistent Incontinence Care
Penalty
Summary
Multiple residents experienced significant delays and omissions in receiving incontinence care, as evidenced by both resident interviews and documentation reviews. One resident reported that after activating her call light at night, a staff member entered, turned off the light, and left without providing care, resulting in her remaining in a wet brief until the next shift. This resident stated that such incidents occurred three to four nights per week, and that staff did not check on her during the night as care plans required. Documentation for this resident showed missing entries for incontinence care across several shifts, indicating a lack of consistent care and documentation. Another resident, who was always incontinent for bladder and bowel, reported that staff response to her requests for incontinence care was slow, often resulting in her waiting over forty-five minutes after urinating before being assisted. This was described as a daily occurrence. Documentation for this resident also revealed missing entries for incontinence care on multiple shifts. Additional residents described similar issues, including long wait times for call lights to be answered, especially during night shifts, and having to remain in soiled briefs for extended periods. One resident reported waiting up to an hour and a half for care, with staff sometimes turning off call lights without providing assistance. Staff interviews corroborated these findings, with CNAs reporting being assigned to care for large numbers of residents alone, making it difficult to provide timely incontinence care. Staff also indicated that care was sometimes left undone between shifts due to heavy workloads and insufficient staffing. The DON acknowledged ongoing struggles with staffing and confirmed that documentation of incontinence care was often incomplete, despite facility policies requiring residents to be checked every two hours and care to be documented on each shift.
Failure to Maintain Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records for three of the seven sampled residents. On October 1, 2024, a Registered Nurse (RN), identified as Staff A, was observed placing used tube feeding bottles with resident-identifiable information into an unsecured, publicly accessible trash can. This occurred for two residents, as the RN detached the feeding tubes from their gastrostomy sites and disposed of the bottles without removing or marking off the resident information. Additionally, the RN left a medication cart unattended with a computer open displaying a resident's medical information and a resident roster exposed on top of the cart. This lapse in security occurred while the RN went to the supply room and again when she returned to provide care to another resident, leaving the information accessible to other residents, staff, and visitors. The Director of Nursing confirmed that staff should have marked off any resident-identifiable information before disposal, as per the facility's policy on resident rights.
Deficiencies in Tracheostomy and Enteral Feeding Care
Penalty
Summary
The facility failed to provide care consistent with the comprehensive person-centered care plan for two residents with tracheostomies. For one resident, the facility did not confirm physician orders related to tracheostomy care, enteral feeding, and medication administration. There were multiple instances where documentation was lacking for essential care activities, such as tracheostomy suctioning, medication administration, and monitoring of vital signs. The resident's care plans indicated the need for enhanced barrier precautions, enteral nutrition, and pain management, but these interventions were not consistently documented as performed. Another resident, who was cognitively intact, also experienced deficiencies in care related to tracheostomy management and enteral feeding. Documentation was missing for the administration of medications, oxygen therapy, and the maintenance of enhanced barrier precautions. The resident's care plans included interventions for nutritional support, pain management, and respiratory care, but these were not consistently documented, indicating a failure to adhere to the prescribed care plan. The Director of Nursing acknowledged the lack of documentation and confirmed that staff were expected to document care activities. The facility's policies required accurate transcription and confirmation of physician orders, as well as documentation of procedures and observations. However, these policies were not followed, leading to gaps in care and documentation for both residents.
Inadequate Tracheostomy and Suctioning Care
Penalty
Summary
The facility failed to provide tracheostomy and suctioning care consistent with professional standards of practice and the resident's comprehensive person-centered care plan for a resident. During an observation, a registered nurse (RN) entered the resident's room without wearing a gown, which was required under enhanced barrier precautions due to the resident's tracheostomy and other medical devices. The RN performed various tasks, including detaching feeding tubes and suctioning the resident, without adhering to proper hand hygiene protocols. The RN did not perform hand hygiene between glove changes and handled equipment and resident care items without appropriate infection control measures. The resident involved had a complex medical history, including anoxic brain damage, respiratory disorders, and acute and chronic respiratory failure, among other conditions. The resident was dependent on staff for care and had a tracheostomy, requiring specific care and precautions. The facility's care plan for the resident included enhanced barrier precautions, which mandated the use of gloves and gowns during high-contact care activities. However, the RN did not follow these precautions, and there was a lack of documentation for tracheostomy care, including the recording of secretions and vital signs post-suctioning. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed that the staff did not follow the expected infection control protocols. The DON confirmed that the RN should have worn a gown and performed hand hygiene between tasks. The ADON, who also served as the Infection Control Preventionist, reiterated the importance of hand hygiene and the proper use of personal protective equipment (PPE). The facility's policies on hand hygiene and barrier precautions were not adhered to, contributing to the deficiency in care provided to the resident.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to standard and enhanced barrier precautions during the care of two residents, leading to a deficiency in infection prevention and control. On multiple occasions, a registered nurse (RN) entered the room of a resident with a tracheostomy and gastrostomy tube without donning a gown, despite the requirement for enhanced barrier precautions. The RN was observed performing various care tasks, such as detaching feeding tubes and suctioning the tracheostomy, without proper hand hygiene between glove changes and without wearing the necessary personal protective equipment (PPE). The RN admitted to not following the enhanced barrier precautions, which were indicated by an orange sign on the resident's door. The resident had multiple medical conditions, including anoxic brain damage and respiratory failure, and required enhanced barrier precautions due to the presence of a tracheostomy, gastrostomy tube, and suprapubic catheter. Despite the facility's policy and the resident's care plan requiring the use of gloves and gowns during high-contact care activities, the RN did not comply with these protocols. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed the expectations for staff to wear appropriate PPE and perform hand hygiene as per the facility's policies. The DON and ADON acknowledged that the RN's actions did not align with the facility's infection control protocols, which emphasize the importance of hand hygiene and the use of gowns and gloves during high-contact care activities to prevent the transmission of infections.
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Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
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