Lake City Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake City, Florida.
- Location
- 298 Sw Prosperity Place, Lake City, Florida 32024
- CMS Provider Number
- 106126
- Inspections on file
- 21
- Latest survey
- April 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lake City Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not ensure proper wound care and medication management for several residents. Two residents had wound dressings that were not changed or documented according to physician orders and facility policy, with missing dates and initials on dressings and incomplete skin assessments. Another resident's medication was held by nursing staff without appropriate parameters or physician clarification, contrary to prescriber orders. These deficiencies were confirmed through observations, record reviews, and staff interviews.
Surveyors found that staff failed to properly store respiratory equipment, did not consistently use required PPE for residents on enhanced barrier precautions, and neglected hand hygiene and equipment cleaning protocols. Staff also handled medications with bare hands and administered pills that had dropped onto unclean surfaces, all in violation of facility infection control policies.
The facility did not ensure the accuracy of MDS assessments for three residents, including incorrect documentation of vision status, use of a feeding tube, and oral/dental status. Staff interviews and resident records confirmed that the MDS entries did not accurately reflect the residents' actual conditions.
A resident was admitted with multiple mental health diagnoses, but the facility failed to ensure the Level I PASRR assessment accurately reflected all relevant conditions as documented in the medical record. The Administrator confirmed the facility did not follow its process to review and correct the PASRR upon admission, resulting in noncompliance with federal screening requirements.
The facility did not develop or implement comprehensive care plans for two residents: one with mental health diagnoses requiring monitoring and another needing enhanced barrier precautions for wound care. Staff confirmed these care needs were not addressed in the residents' care plans, contrary to facility policy and federal requirements.
A resident did not receive a physician-agreed pharmacy recommendation for vitamin D3 supplementation, as the order was not entered into the electronic medical record despite documented agreement. Staff interviews confirmed the expectation that such recommendations be acted upon, but the process was not completed as required by facility policy.
A resident continued to receive an extended-release medication without a stop date, despite the consultant pharmacist's recommendation to evaluate the need and consider discontinuation. The physician's responses were inconsistent, and facility staff did not ensure that the medication orders were updated in the electronic medical record, leading to ongoing administration of the drug without adequate justification.
Surveyors found that several residents had unauthorized access to medications and biologicals in their rooms, including sprays, lubricants, powders, and an unattended pill. Staff confirmed that no residents were authorized to self-administer medications, and facility policy required secure storage and proper assessment before allowing self-administration. Medications and biologicals were not stored according to professional standards or facility policy.
A resident was not provided with timely dental services after losing dentures, resulting in the need for a mechanical soft diet. Delays were attributed to insurance and referral processes, and although staff documented the resident's ability to eat, the lack of dentures remained unresolved.
Surveyors found that food items in both the kitchen walk-in freezer and nourishment room refrigerator were not labeled or dated as required by facility policy. The Dietary Manager confirmed that these items should have been labeled and dated, indicating a failure to follow professional standards for food service safety.
A resident who previously participated in a restorative program did not receive required specialized rehabilitative services or evaluations after the program was discontinued, despite active physician orders and care plan interventions indicating ongoing need. Facility staff confirmed that the transition to a new functional maintenance program did not include proper evaluation or continuity of care for this resident, resulting in a lapse in required services.
Surveyors found that staff failed to maintain complete and accurate medical records for several residents, including improper documentation of behavioral monitoring, medication administration, and wound care. Errors included incomplete behavioral documentation, incorrect transcription of a medication order, lack of provider notification documentation when medications were held, and false documentation of wound care based on unverified reports from other staff.
The facility did not maintain an effective QAPI program for monitoring and documenting significant weight loss, as two residents identified for weight loss were not weighed according to the required weekly schedule, and there was no documentation of required risk meetings or monitoring. The DON confirmed the absence of documentation and a set plan during the transition to a new program, resulting in a lack of evidence that the QAPI processes were followed.
The facility did not establish or follow an effective antimicrobial stewardship program, as evidenced by two residents receiving antimicrobials without proper assessment, documentation, or diagnostic testing. Staff interviews indicated that providers often prescribed antimicrobials without required testing or review, and facility policy requirements for monitoring and review were not met.
Surveyors found that the generator annunciator panel, located behind the central nurses station, was not powered and appeared disconnected or disabled. This issue was confirmed by the Maintenance Director and acknowledged by facility leadership.
Surveyors found that the facility did not have documentation showing its Emergency Preparedness Program (EPP) was reviewed and updated annually, as required. Both the Administrator and Maintenance Director acknowledged the lack of annual review records during the survey.
The facility did not maintain the kitchen hood fire suppression system as required, failing to provide documentation for a semiannual inspection and leaving previously noted discrepancies uncorrected. This was confirmed by both the Administrator and Maintenance Director.
The facility did not ensure all fire alarm system devices, including duct detectors, were tested and maintained as required, and lacked documentation of biennial smoke detector sensitivity testing. Additionally, a smoke detector was found improperly placed near an HVAC supply vent. These issues were confirmed by facility leadership.
Surveyors found that the facility could not provide documentation of the required 5-year internal backflow inspection for the sprinkler system, and the fire backflow device was observed to be 'Red Tagged' and inoperable. These deficiencies were confirmed by facility leadership.
The facility did not provide documentation of annual inspections or evidence of a trained, certified individual responsible for fire and smoke door assemblies, as required by NFPA standards. This deficiency was confirmed by facility leadership during interviews and record review.
The facility did not maintain required documentation for the emergency generator engine and failed to perform annual diesel fuel testing as required by NFPA standards. These deficiencies were confirmed by the Maintenance Director and acknowledged by facility leadership.
The facility did not provide adequate documentation for the four-year fire and smoke damper inspection, as required by NFPA 80, with vendor records lacking details on the number, locations, and type of dampers. This deficiency was acknowledged by facility leadership.
Failure to Provide Proper Wound Care and Medication Management
Penalty
Summary
The facility failed to provide appropriate care and treatment for multiple residents, as evidenced by observations, interviews, and record reviews. For one resident with multiple abdominal and limb dressings, there were inconsistencies and omissions in wound care documentation and execution. The resident reported that dressings were last changed several days prior, and staff were unaware of all wound sites. Physician orders for wound care were not consistently followed, and some dressings lacked required labeling with date and initials. Staff interviews revealed a lack of clarity regarding responsibility for wound care on weekends and incomplete skin assessments upon admission. Another resident was observed with a dressing on her limb that had a dried dark substance and was missing date and initials, contrary to facility policy and physician orders. The resident stated the dressing was due to an injury, but the required documentation and proper dressing maintenance were not evident during multiple observations. The Director of Nursing confirmed that all dressings should be dated and initialed, which was not done in this case. Additionally, a third resident's medication was held by nursing staff without appropriate parameters or physician clarification, as indicated by the Medication Administration Record and staff interviews. The DON acknowledged that the medication was held without proper orders, and the facility's policy requires medications to be administered according to prescriber orders and standards of practice. These findings demonstrate failures in following professional standards, care plans, and physician orders for both wound care and medication management.
Infection Control Deficiencies in Equipment Handling, PPE Use, and Hand Hygiene
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control practices. Staff failed to properly store respiratory equipment, such as passive masks and tubing, for several residents. In multiple instances, these items were left unbagged on surfaces or on the floor, contrary to facility policy and staff expectations that such equipment should be bagged when not in use. Additionally, disposable equipment was not consistently labeled or changed as required. Staff did not consistently adhere to enhanced barrier precautions (EBP) for residents with medical devices or those requiring such precautions. Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) were observed providing direct care, including dressing, toileting, and medication administration, to residents on EBP without wearing the required gowns, and in some cases, staff were unaware that residents were on EBP. The Director of Nursing (DON) confirmed that staff are expected to wear both gloves and gowns when providing care to residents under EBP, and that some residents who met criteria for EBP did not have appropriate orders in place. Hand hygiene and equipment cleaning protocols were not followed during resident care and medication administration. Staff were observed changing gloves multiple times without performing hand hygiene in between, despite facility policy and DON statements that hand hygiene is required between glove changes. Medical equipment, such as blood pressure cuffs and pulse oximeters, was used on multiple residents without cleaning between uses. Additionally, staff handled oral medications with bare hands and administered medications that had dropped onto unclean surfaces. These actions were inconsistent with facility policies and accepted standards for infection prevention and control.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents. For one resident, the MDS inaccurately documented that the resident had adequate vision without corrective lenses, despite both the resident's son and a registered nurse confirming the resident's vision was impaired and required corrective lenses. The optometry evaluation also indicated the use of corrective lenses, and the MDS Coordinator acknowledged the inaccuracy in the assessment. Another resident was reported to be using a tube for medication administration, but the MDS assessment did not reflect the presence of the tube or any related nutritional approaches. The MDS Coordinator confirmed this was incorrect. Additionally, a third resident, who was on a mechanical soft diet due to a broken dental appliance, was not accurately represented in the MDS under the oral/dental status section. The resident expressed frustration about not having the dental appliance, and the MDS Coordinator admitted the annual assessment was marked incorrectly.
Failure to Complete Accurate PASRR Assessment for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) was completed for one resident who was reviewed for unnecessary medications. The resident was admitted with diagnoses including major depressive disorder and other mental health conditions. The Level I PASRR for this resident listed certain mental illnesses but omitted others, despite documentation in the hospital discharge summary and the Minimum Data Set (MDS) assessment indicating additional relevant diagnoses. The facility's policy requires that all individuals being admitted have a completed PASRR Level I prior to admission, and that the PASRR be reviewed for accuracy and corrected if necessary. During an interview, the Administrator acknowledged that the facility did not follow its process to review and correct the PASRR upon the resident's admission from the hospital. The resident's medical records, including a visit note and hospital discharge summary, documented a history of multiple mental health conditions that were not fully reflected in the PASRR. This failure to ensure an accurate PASRR assessment resulted in noncompliance with federal requirements for preadmission screening for individuals with mental illness or intellectual disability.
Failure to Develop and Implement Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents as required by federal regulations. For one resident with diagnoses including generalized anxiety and post-traumatic stress disorder, the care plan did not include a focus or interventions addressing these mental health conditions, despite physician orders and clinical notes indicating the need for monitoring and documentation of related symptoms. Staff interviews confirmed that these diagnoses and their associated care needs were not incorporated into the resident's care plan and needed to be added. For another resident, physician orders and clinical documentation indicated the need for enhanced barrier precautions due to a medical device and wound care requirements. However, the resident's care plan did not address enhanced barrier precautions, and staff interviews, including those with the LPN Unit Manager, DON, and MDS Coordinator, confirmed that this omission was inconsistent with facility expectations and policy. The facility's policy requires the identification of problem areas and the development of targeted interventions, which was not followed in these cases.
Failure to Implement Physician-Agreed Pharmacy Recommendation
Penalty
Summary
The facility failed to ensure that a physician-agreed medication regimen recommendation from the consultant pharmacist was implemented for one resident. The consultant pharmacist recommended that the resident receive vitamin D3, 1000 IU once daily, based on clinical guidelines for elderly individuals to maintain bone health. The attending physician reviewed this recommendation and documented agreement with the plan, indicating, "Agree; will do." However, a review of the resident's current physician orders revealed that no order for vitamin D3 had been entered. Interviews with facility staff, including the DON and a nurse practitioner, confirmed that the process for addressing pharmacy recommendations involves unit managers and the ADON updating the electronic medical record when a provider agrees to a recommendation. Despite this expectation, the agreed-upon order was not entered. The facility's policy requires that drug regimen review recommendations be acted upon, but in this case, the necessary follow-through did not occur, resulting in the deficiency.
Failure to Address Pharmacist's Recommendation for Unnecessary Drug
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary drugs, as required by federal regulations. Specifically, the consultant pharmacist identified that the resident was receiving a long-acting medication without a stop date and recommended evaluating the current need and considering adding a stop date. The physician initially agreed to discontinue the medication but later disagreed, stating the medication was to be given as needed (PRN). Despite these recommendations and responses, the resident continued to receive the extended-release medication twice daily, as documented in the Medication Administration Records over an extended period. Interviews with facility staff, including the DON and a Nurse Practitioner, revealed that the process for addressing consultant pharmacist recommendations involved dividing the recommendations among unit managers and the ADON, with the expectation that any provider orders should be updated in the electronic medical record. The facility's policy required that drug regimen reviews be conducted monthly and that any irregularities be reported and acted upon, with documentation of the physician's review and actions taken. However, the records showed that the recommendations regarding the medication were not properly addressed or documented, resulting in the continued administration of the medication without adequate justification or a stop date.
Improper Storage and Unauthorized Access to Medications
Penalty
Summary
Surveyors observed multiple instances where drugs and biologicals were not stored in accordance with professional standards and facility policy. In one case, a resident had a bottle of spray at their bedside, which the resident reported using at night. Staff confirmed that residents are not permitted to self-administer medications without an evaluation, care plan, and physician order, none of which were in place for this resident. Another resident had a bottle of lubricant and powder on their bedside table and air conditioning unit, stating that they used these items as needed, sometimes with nurse assistance. A third resident had a tube of an unidentified substance at their bedside, which staff confirmed was not ordered and was brought in by family without staff knowledge or approval. In each case, staff acknowledged that the residents were not authorized to self-administer medications and that such items should not be accessible without proper assessment and documentation. Additionally, a medication cup containing a white pill was found unattended in a resident's room. The resident was unaware of the medication's purpose, and the LPN stated they believed the resident had already taken all medications. The DON confirmed that no residents in the facility were authorized to self-administer medications and that medications should not be left unattended in resident rooms. Facility policies reviewed by surveyors required that medications be stored securely and that self-administration only occur following interdisciplinary assessment and physician order, which was not followed in these instances.
Failure to Provide Timely Dental Services for Lost Dentures
Penalty
Summary
The facility failed to ensure that a resident received necessary dental services, specifically the replacement of lost or damaged dentures. The resident reported being on a mechanical soft diet solely due to the absence of dentures, expressing dissatisfaction with the inability to eat properly. Interviews with facility staff revealed that the process for obtaining dental services was delayed due to insurance requirements and the need for a referral from the resident's primary office to a dental clinic. Documentation in the medical record indicated that dental referrals were sent and that attempts were made to locate the resident's dentures for evaluation, but the dentures were not found, and the resident remained without them. Further review of the resident's records showed that dental consultations noted the absence of dentures and the resident's interest in obtaining a new set. Staff documented that the resident was able to obtain adequate nutrition and was not experiencing discomfort, but the only reason for the mechanical soft diet was the lack of dentures. The facility's policy required referral for dental services within three days of loss or damage of dentures, or documentation of actions taken and reasons for delay, but the report indicates ongoing delays and lack of resolution for the resident's dental needs.
Failure to Label and Date Stored Food Items
Penalty
Summary
Surveyors observed that the facility failed to ensure proper food storage practices in both the kitchen walk-in freezer and the nourishment room refrigerator. During an initial kitchen tour with the Dietary Manager, a plastic see-through bag containing unidentified food items was found in the walk-in freezer without any label or date. The Dietary Manager confirmed that the item should have been labeled and dated, in accordance with the facility's food storage policy, which requires all frozen foods to be covered, labeled, and dated. Additionally, in the nourishment room refrigerator on Desota Hall, a bag containing wrapped crackers and a bowl of covered food were found without dates. The Dietary Manager again acknowledged that these items should have been dated. The facility's policy for foods brought in by family or visitors also requires perishable foods to be stored in resealable containers with tight-fitting lids, labeled with the resident's name, item name, and a use-by date, with nursing staff responsible for discarding perishable foods on or before the use-by date. These observations indicate that the facility did not follow its own policies and professional standards for food service safety regarding labeling and dating stored food items.
Failure to Provide Required Specialized Rehabilitative Services After Program Discontinuation
Penalty
Summary
The facility failed to provide or obtain specialized rehabilitative services as required for one resident who was previously participating in a restorative program. The resident reported that after the facility discontinued the restorative program, no further rehabilitative services or evaluations were provided, despite active physician orders for evaluation and treatment. The resident's care plan indicated a need for a functional maintenance program due to self-care performance issues following an infraction affecting the left dominant side, but no current interventions were implemented after the program was discontinued. Interviews with facility staff, including the Functional Maintenance Coordinator, DON, and Rehabilitation Director, confirmed that the restorative program was ended and replaced with a functional maintenance program. However, the resident in question was not evaluated or included in the new program, and quarterly assessments were not conducted as required. Staff acknowledged that there was no process in place to ensure continuity of care for residents transitioning from the discontinued program, and the lack of evaluation was attributed to oversight or human error.
Deficient Medical Record Documentation and Incomplete Medication and Wound Care Records
Penalty
Summary
Surveyors identified multiple deficiencies related to the maintenance of complete and accurate medical records for several residents. For one resident with behavioral monitoring orders, staff failed to document required observations as specified by the physician, instead marking an 'X' rather than indicating 'yes' or 'no' for the presence of behaviors, and did not provide corresponding progress notes when behaviors were observed. The Director of Nursing confirmed that the documentation was incomplete and did not follow the order's requirements. For two residents receiving medication management, there were errors in both the transcription and documentation of medication orders and administration. One resident's medication order was transcribed incorrectly, using the wrong symbol for a critical parameter, which was acknowledged by both the DON and an Advanced Practice Registered Nurse. Another resident had insulin doses held due to low blood sugar readings, but staff failed to document provider notification or the rationale for withholding the medication in the nurses' notes, as required by facility policy and standard practice. Additionally, for a resident requiring daily wound care, staff documented that care was provided on days when it was actually performed by another nurse, without verifying completion. The responsible nurse admitted to documenting care based on verbal reports rather than direct observation or confirmation, and a unit manager confirmed that documenting care not personally completed constitutes false documentation. Facility policy requires detailed documentation of wound care, including date, time, and wound appearance, which was not consistently followed.
Failure to Maintain Effective QAPI Program for Weight Loss Monitoring
Penalty
Summary
The facility failed to maintain an effective, data-driven Quality Assurance and Performance Improvement (QAPI) program as required by federal regulations. Specifically, the facility did not provide evidence of ongoing monitoring and documentation for a performance improvement plan (PIP) related to weight loss among residents. The QAPI program was expected to include systematic identification, reporting, investigation, analysis, and prevention of adverse events, as well as documentation of corrective actions and performance improvement activities. However, the facility was unable to demonstrate that these processes were consistently followed for residents experiencing significant weight loss. A review of the facility's Loss Performance Improvement Plan indicated that residents who experienced significant weight loss were to be reviewed weekly in risk meetings until their weight stabilized for four weeks. The plan also required appropriate notifications, Registered Dietitian consults, care plan updates, and consistent weighing practices. Despite these outlined procedures, documentation revealed that two residents identified for monitoring were not weighed according to the prescribed weekly schedule, and there was no proof of weekly risk meetings or adequate monitoring as required by the plan. During interviews, the Director of Nursing (DON) acknowledged the lack of a set plan for transitioning from restorative to a Functional Maintenance Program and admitted that documentation for weekly monitoring and meetings was not available. The facility's QAPI policy required identifying issues, developing and implementing corrective actions, and reviewing and analyzing data, but the facility was unable to provide evidence that these steps were followed for the residents in question.
Failure to Implement Effective Antimicrobial Stewardship Program
Penalty
Summary
The facility failed to establish and implement an effective stewardship program to monitor the use of antimicrobials for two residents. For one resident, a physician ordered a preventative antimicrobial regimen without documented consideration of a 'time out' or pause to reassess the need for continued therapy. The Advanced Practice Registered Nurse (APRN) admitted to not having considered a time out and was unable to provide documentation of the clinical assessment that led to the order, citing issues with transitioning records. The Assistant Director of Nursing (ADON) also could not provide documentation of discussions with providers regarding antimicrobial use. For another resident, antimicrobials were ordered without any diagnostic testing to confirm the need for such treatment. The Director of Nursing (DON) confirmed that no test was ordered and that the provider prescribed the medication without testing. Staff interviews revealed that a physician frequently prescribed antimicrobials based on symptoms alone, such as coughing, without ordering diagnostic tests, and that staff felt unable to discontinue these medications once the provider had spoken to the resident. Review of the facility's stewardship policy indicated that regular review of antimicrobial utilization and laboratory reports was required, but these practices were not followed in the cases reviewed.
Generator Annunciator Panel Found Disconnected
Penalty
Summary
During a facility tour, surveyors observed that the generator annunciator panel, which is required to be powered and located in a place readily observed by operating personnel, was found to have no power. The panel was located on the wall behind the central nurses station near the central hallway. Testing of the annunciator revealed it was disconnected or disabled, and this was confirmed by the Maintenance Director during the tour. The deficiency was acknowledged by both the Administrator and the Maintenance Director during the exit conference. No information regarding residents or their medical conditions was included in the report.
Failure to Annually Review and Update Emergency Preparedness Program
Penalty
Summary
The facility failed to review and update its Emergency Preparedness Program (EPP) as required by federal regulations. During a record review with the Administrator and the Maintenance Director, surveyors found that there was no documented evidence showing the EPP had been reviewed and updated annually. This deficiency was identified during the survey process when the facility was unable to provide records demonstrating compliance with the annual review and update requirement for the EPP. Both the Administrator and the Maintenance Director acknowledged the absence of documentation regarding the annual review and update of the EPP during the exit conference. The Maintenance Director also concurred with the findings during the interview. No information was provided in the report regarding specific residents or their conditions at the time of the deficiency.
Failure to Maintain Kitchen Hood Fire Suppression System
Penalty
Summary
The facility failed to maintain the kitchen hood cooking fire suppression system in accordance with required inspection and maintenance protocols. During a record review with the Administrator and Maintenance Director, it was found that the facility could not provide documentation for one of the required semiannual maintenance inspections. The last available semiannual inspection, dated 7/29/24, indicated discrepancies that had not been corrected, and this was confirmed during the facility tour. Both the Administrator and Maintenance Director acknowledged these findings during the exit conference. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Fire Alarm System Testing and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with NFPA 72 standards. During a record review with the Administrator and Maintenance Director, it was found that not all fire alarm devices had been tested, inspected, and maintained as required. Specifically, 5 out of 12 duct detector devices were missed during testing and were reported as not accessible by the fire alarm vendor. Additionally, the facility could not provide documentation showing that biennial sensitivity testing of smoke detectors had been conducted, with no records available to indicate when the last such testing occurred. During a facility tour, a smoke detector was observed to be within 36 inches of an HVAC supply vent in the main service hallway, which does not comply with placement requirements. These deficiencies were acknowledged by both the Administrator and the Maintenance Director during the exit conference. No information about specific residents or their conditions was provided in relation to these deficiencies.
Failure to Maintain Sprinkler System and Provide Required Inspection Documentation
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 101 requirements. During a record review with the Administrator and Maintenance Director, the facility was unable to provide documentation of the required 5-year internal backflow inspection report. Additionally, during a facility tour, surveyors observed that the fire backflow device located at the main entrance was 'Red Tagged,' indicating that the system was in failure and inoperable. These findings were confirmed by the Maintenance Director during the interview and acknowledged by both the Administrator and Maintenance Director at the exit conference. No information about residents or their medical conditions was included in the report.
Failure to Maintain and Inspect Fire and Smoke Door Assemblies
Penalty
Summary
The facility failed to provide regular inspections, testing, and maintenance of fire and smoke door assemblies as required by NFPA 80 and NFPA 105. During a record review with the Administrator and Maintenance Director, the facility was unable to produce documentation of annual inspections for smoke doors or evidence of training for a competent, certified individual responsible for fire and smoke doors. This lack of documentation and training was confirmed during interviews with facility leadership. The deficiency was acknowledged by both the Administrator and the Maintenance Director during the exit conference. No information was provided regarding specific residents or patient conditions related to this deficiency. The report focuses solely on the absence of required inspection records and training for fire and smoke door assemblies.
Failure to Maintain Emergency Power System and Annual Diesel Fuel Testing
Penalty
Summary
The facility failed to maintain its Emergency Power System (EPS) in accordance with NFPA 80 and NFPA 110 requirements. During a record review with the Administrator and Maintenance Director, it was found that the emergency generator engine manufacturer's recommendations were not available for reference. Additionally, the facility did not conduct the required annual testing of the generator's diesel fuel as specified by the relevant codes. These deficiencies were confirmed during interviews with the Maintenance Director, who concurred with the findings. The lack of documentation and failure to perform the mandated fuel testing were acknowledged by both the Administrator and Maintenance Director during the exit conference. No information about residents or their conditions was provided in the report.
Failure to Document Fire and Smoke Damper Inspections per NFPA Standards
Penalty
Summary
The facility failed to maintain proper documentation for the four-year fire and smoke damper inspection, testing, and maintenance as required by NFPA 80. During a record review with the Administrator and Maintenance Director, it was found that the vendor documentation only indicated that the fire and smoke dampers were functioning, but did not specify the number of dampers, their locations, or the type of system installed. This lack of detailed documentation meant the facility could not demonstrate compliance with the required standards for maintaining the integrity of the fire alarm system to ensure proper alarm and safe relocation of residents, staff, or other building occupants in the event of a fire. These findings were confirmed by both the Administrator and the Maintenance Director during the exit conference.
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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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