Lake Haven Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dunedin, Florida.
- Location
- 1351 San Christopher Dr, Dunedin, Florida 34698
- CMS Provider Number
- 105350
- Inspections on file
- 23
- Latest survey
- October 13, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Lake Haven Nursing And Rehab Center during CMS and state inspections, most recent first.
Two residents with complex medical conditions did not receive weekly skin checks as required by physician orders and care plans. Documentation in the EMR was incomplete, and staff interviews revealed a lack of consistent scheduling and follow-through for skin assessments. The facility's policy for weekly skin evaluations by licensed nurses was not adhered to, resulting in a deficiency in care.
Three residents with significant wounds and pressure ulcers did not receive timely or consistent wound care as ordered by physicians. Documentation showed delays in obtaining and implementing wound care orders, incomplete treatment records, and lack of wound care for some wounds. Nursing staff and the DON confirmed that required admission assessments and prompt physician notification for wound care were not consistently performed.
A resident's Nursing Admission Screening/History was left incomplete and blank at the time of admission, with essential assessment sections missing. Over a month after the resident's discharge, an LPN completed and locked the assessment at the request of the CNO, despite not having performed the original admission. The CNO confirmed this was not appropriate and that the facility lacked a specific policy for admission documentation.
Two residents in an LTC facility did not receive therapeutic diets as ordered by their physicians. One resident, at risk for aspiration, was given a mechanical soft diet instead of the required pureed diet due to a missing dietary change form. Another resident, who needed double portions for weight management, did not receive the correct meal portions. The facility lacked a policy for following meal tickets, leading to these deficiencies.
Two residents in a facility did not receive their prescribed therapeutic diets, leading to deficiencies in dietary services. One resident, requiring a pureed diet and double protein portions, was given a mechanical soft diet due to staff's lack of awareness of dietary changes. Another resident, needing double protein portions, received only a single portion despite the meal ticket indicating otherwise. The facility lacked a policy for ensuring dietary orders were followed, resulting in residents not receiving appropriate nutrition.
A CNA was witnessed abusing two residents, slapping them during care. The incident was not reported immediately due to fear, leaving other residents at risk. Both residents were non-verbal and dependent on staff for care. The facility's abuse prevention policy was not followed, leading to a failure to protect vulnerable residents.
A facility failed to report an incident of abuse by a CNA towards two residents in a timely manner. The residents, who were non-verbal and highly dependent on staff, were physically abused by the CNA, leaving a handprint on one. The incident was not reported immediately due to fear of retaliation, and the facility's policy for immediate reporting was not followed, leading to a significant deficiency.
The facility failed to maintain an effective infection prevention and control program, with deficiencies including not reporting rashes to the health department, not changing a blood-stained pillowcase for a resident with a bloodborne pathogen, and not sanitizing a glucometer after use. The DON/IP was unaware of scabies treatment for residents, and infection control protocols were not followed during medication administration.
The facility failed to maintain a clean and safe environment, with observations of unsanitary conditions in resident rooms, bathrooms, and common areas. Issues included petrified worms, brown and black stains, debris accumulation, and exposed wires on bed remotes. Interviews with the Maintenance Director and Nursing Home Administrator confirmed the deficiencies, highlighting a failure to adhere to cleaning policies. Photographic evidence supported the findings, indicating a systemic issue affecting multiple areas.
The facility failed to ensure accurate accountability and storage of controlled medications in two medication carts. Discrepancies were found in the narcotic count, including loose pills and incorrect records for Clonazepam, Oxycodone, Tramadol, and Hydrocodone/APAP tablets. A card for a discharged resident was also found. An LPN admitted to not signing out medications due to a hectic morning, and the DON was unaware of the issue, indicating a failure to follow facility policies on controlled substances and medication storage.
A facility reported a 28.57% medication error rate, with errors including incorrect dosages and improper medication handling. An LPN administered incorrect doses via a G-tube, and an RN crushed extended-release medications, mixing them with pudding. Another LPN failed to prime an insulin pen before use. Interviews confirmed these practices did not align with guidelines.
The facility failed to provide a dignified dining experience for three residents during assisted dining. A CNA was observed standing while assisting a resident with amyotrophic lateral sclerosis, despite a chair being available. Another CNA stood while feeding a resident and later sat on a resident's bed, citing a lack of chairs. The facility's policy emphasizes a dignified existence, which was not upheld.
A resident with a moderately impaired mental status was moved to a new room without prior notice or explanation. The facility failed to document the room change or communicate the reason to the resident, contrary to its policy requiring advance notice and documentation.
A resident with a shoulder wound did not receive wound care as per physician orders, resulting in missed treatments and lack of documentation. The resident's care plan did not address the wound, and staff confirmed the absence of documented treatments. The facility's policy required treatment per physician order, which was not followed.
The facility failed to properly store respiratory equipment for two residents, leading to unsanitary conditions. One resident's oxygen tubing was found on the floor, while another's tubing had not been changed as per physician orders. Staff interviews revealed a lack of understanding and absence of a policy for storing respiratory equipment.
The facility failed to properly store and secure medications, with unlocked cabinets and carts containing resident medications, unlabeled insulin pens, and loose pills. The DON struggled to secure the narcotic box due to key access issues, and medication carts were left unattended, violating facility policy.
A resident with amyotrophic lateral sclerosis, who was cognitively intact, was served green beans and spicy sausage despite documented dislikes. The CNA did not check the meal ticket for dislikes, and the resident was not offered an alternative. The CDM, DON, and NHA acknowledged the failure to follow the process for honoring meal preferences.
A facility failed to ensure hospice services were provided according to professional standards due to poor communication and documentation for a resident with advanced dementia. Despite a physician order for hospice care, there was no documentation in the resident's progress notes or care plan. Interviews revealed communication issues between facility staff and the hospice provider, with the DON noting a lack of documentation from the hospice nurse.
Failure to Complete and Document Weekly Skin Checks for Two Residents
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, specifically regarding the completion of weekly skin checks for two residents. For one resident with multiple diagnoses including vascular dementia, chronic kidney disease, and diabetes, physician orders required weekly skin checks. However, review of the electronic medical record revealed only one documented skin evaluation during the resident's stay, despite the presence of scratches and dried blood on the arms. Additionally, there was no care plan addressing skin integrity or weekly skin checks for this resident. Interviews with nursing staff and the acting DON confirmed that weekly skin checks were not performed or documented as required. For another resident with diagnoses such as osteomyelitis, hepatitis B, and septic pulmonary embolism, the care plan included weekly skin checks due to impaired or at-risk skin integrity. Despite this, the medical record showed only one skin evaluation, and there was no evidence of a weekly skin assessment schedule or documentation of skin checks for this resident. Staff interviews revealed that the unit did not have a weekly skin assessment schedule in place, and the DON acknowledged the missing assessment, stating that a provider's note was being counted as a skin assessment, although this did not meet the facility's policy requirements. The facility's policy required licensed nurses to complete and document weekly skin evaluations for all residents. Observations, interviews, and record reviews demonstrated that this policy was not consistently followed, resulting in a failure to provide care and treatment according to physician orders, resident care plans, and professional standards of practice for the two residents involved.
Failure to Provide Timely and Consistent Wound Care per Physician Orders
Penalty
Summary
The facility failed to provide appropriate wound care treatment and follow physician orders for three residents who were admitted with significant skin and wound care needs. For one resident, the admission records and physician documentation indicated multiple skin tears and wounds requiring specific dressing changes and wound care regimens. However, the treatment administration record showed that wound care orders were not implemented upon admission, and wound care was only documented once during the resident's stay. The resident's responsible party also reported that wound care was not provided consistently. Another resident was admitted with multiple pressure ulcers and wounds, including stage IV pressure areas and an unstageable wound. Physician orders and wound care consults were documented, specifying daily wound care treatments for several sites. Despite this, the facility's records lacked documentation of wound care being provided until several days after admission, and initial orders did not cover all identified wounds. The nursing admission assessment confirmed the presence of multiple wounds, but corresponding treatment orders were incomplete or delayed. A third resident was admitted for wound care with several unstageable pressure ulcers documented on admission forms and nursing assessments. Despite the clear need for wound care, the facility's records did not contain any wound care orders for this resident. Interviews with nursing staff and the Director of Nursing confirmed that the facility's policy required prompt skin assessments and obtaining physician orders for treatment upon admission, but this process was not followed for these residents. The Director of Nursing acknowledged that the facility's expectations for wound care assessment and treatment were not met in these cases.
Incomplete and Late Documentation of Admission Assessment
Penalty
Summary
The facility failed to ensure that medical records were completed and accurate for one resident out of three sampled. Upon review, the Nursing Admission Screening/History for a resident admitted from the hospital and later discharged was found to be blank except for auto-populated vital signs. Key sections such as admission details, neurological status, social history, physical assessments, and medication information were not documented at the time of admission. The assessment remained incomplete and unlocked in the electronic medical record system until more than a month after the resident's discharge. On the day of the survey, a staff LPN/Unit Manager completed and locked the previously blank assessment at the request of the Chief Nursing Officer (CNO) to print the document. The LPN admitted to filling out the assessment despite not having performed the original admission, and the CNO confirmed that this was not appropriate practice. The CNO also acknowledged that the facility did not have a specific policy for documentation of admission assessments, and that documentation should have been completed within 72 hours of admission, not after discharge.
Failure to Provide Therapeutic Diets as Ordered
Penalty
Summary
The facility failed to provide a therapeutic diet according to physician orders for two residents, leading to deficiencies in their care. Resident #1, who was admitted with medical diagnoses including cerebral infarction and dysphagia, was observed not receiving the appropriate pureed diet and thickened liquids as ordered. Despite the speech therapist's recommendation to downgrade his diet to pureed due to aspiration risk, the dietary manager was unaware of the change, resulting in Resident #1 receiving a mechanical soft diet instead. This miscommunication was attributed to a missing dietary change form, which was not properly processed in the dietary system. Resident #25, who was supposed to receive double portions of protein due to weight loss, did not receive the correct meal portions as per his dietary orders. During a lunch observation, it was noted that he received only one Salisbury steak patty instead of the double portion indicated on his meal ticket. The facility's Registered Dietician confirmed the oversight and acknowledged that the meal ticket was not followed, which should have been caught by the tray line staff. The lack of adherence to the meal ticket resulted in Resident #25 not receiving the necessary nutritional support to address his weight loss. The facility's dietary management process was found to be lacking, as there was no policy or procedure in place for following and honoring meal tickets and diets. The dietary staff, including the cook and dietary aide, were unable to explain how the errors occurred, indicating a systemic issue in the meal service process. The absence of a structured protocol for ensuring dietary orders are accurately followed contributed to the deficiencies observed in the care of both residents.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Identified resident #1: Resident was provided an additional serving of protein during lunch meal service per physician order. Diet orders were reviewed by the Chief Nursing Officer. Tray ticket updated with Puree diet per physician order and Speech recommendations. Resident did not suffer any adverse effects from not receiving the proper diet texture. Resident #1 was assessed by the APRN. APRN progress notes documented: CTA. No chills or increased in decrease in SPO2 noted. No. Identified resident #25 was provided an additional serving of protein per physician order during lunch meal service (205). (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quality review completed by Certified Dietary Manager/designee to ensure the residents receive meals per physician order, tray tickets match the physician order and residents receive double portions/2x entrees. Quality review completed by the DON/designee ensuring residents are provided with snacks when requested to be completed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Dietary staff re-educated by the Certified Dietary Manager on the components of this regulation and that residents receive meals per physician order, tray tickets match the physician order, tray line validates what is served match the tray ticket and residents receive double portions/2x entrees. When the Dietary Manager is not present, the dietary staff will update the sheet located in the kitchen to document new admissions, re-admissions or diet changes and update the pre-printed tickets with changes, write a ticket with new admissions/re-admissions for the Dietary Manager to input in the tray card system upon return to the center completed. Current Certified Nursing Assistants re-educated by the DON/designee regarding ensuring residents receive snacks upon request to be completed. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; Certified Dietary Manager/designee to conduct ongoing quality monitoring through visual observation of the tray line and meal service in the dining room to ensure residents are provided meals per physician order 5 x weekly x 4 weeks, 3 x weekly x 4 weeks, twice weekly x 4 weeks then weekly and PRN as indicated. DON/designee to conduct ongoing quality monitoring through resident interview and observation to ensure snacks are provided upon request 3 x weekly x 2 weeks, twice weekly x 2 weeks then weekly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months then quarterly and PRN as indicated and modified based on findings.
Failure to Provide Therapeutic Diets as Prescribed
Penalty
Summary
The facility failed to provide therapeutic diets according to physician orders for two residents, leading to deficiencies in dietary services. Resident #1, who was admitted with medical diagnoses requiring a specific diet, did not receive the prescribed pureed texture and double portion protein/entrée at each meal. During an observation, Resident #1 was given a mechanical soft diet instead of the required pureed diet, and staff were unaware of the resident's dietary needs. The Dietary Manager was not informed of the diet change, resulting in the resident receiving incorrect meal portions. Resident #25 also did not receive the prescribed double portions of protein as indicated in the physician's orders. Despite the meal ticket specifying double portions, the resident received only one patty of Salisbury steak instead of two. The Registered Dietician confirmed that the resident should have received double portions due to previous weight loss and the need for increased nutritional intake. The facility's dietary staff failed to follow the meal ticket instructions, leading to the resident not receiving the necessary dietary support. The facility lacked a policy and procedure for following and honoring meal tickets and diets, contributing to the oversight in providing the correct meals to residents. The dietary staff, including the Cook and Dietary Aide, were unable to explain how the error occurred, indicating a lack of communication and oversight in the dietary service process. The absence of a structured protocol for ensuring dietary orders are followed resulted in residents not receiving the appropriate nutrition as prescribed by their physicians.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Identified resident #1: Resident was provided an additional serving of protein during lunch meal service per physician order. Diet orders were reviewed by the Chief Nursing Officer. Tray ticket updated with Puree diet per physician order and Speech recommendations. Resident did not suffer any adverse effects from not receiving the proper diet texture. Resident #1 was assessed by the APRN. APRN progress notes documented: CTA. No chills or increase in or No decrease in SPO2 noted. Identified resident #25 was provided an additional serving of protein per physician order during lunch meal service. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review completed by Certified Dietary Manager/designee to ensure the residents receive meals per physician order, tray tickets match the physician order, and residents receive double portions/2x entrée. Quality review completed by the DON/designee r/t ensuring residents are provided with snacks when requested to be completed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Dietary staff re-educated by the Certified Dietary Manager on the components of this regulation and that residents receive meals per physician order, tray tickets match the physician order, tray line validates what is served match the tray ticket, and residents receive double portions/2x entrée. When the Dietary Manager is not present, the dietary staff will update the sheet located in the kitchen to document new admissions, re-admissions, or diet changes and update the pre-printed tickets with changes, write a ticket with new admissions/re-admissions for the Dietary Manager to input in the tray card system upon return to the center completed. Current Certified Nursing Assistants re-educated by the DON/designee r/t ensuring residents receive snacks upon request to be completed. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Certified Dietary Manager/designee to conduct ongoing quality monitoring through visual observation of the tray line and meal service in the dining room to ensure residents are provided meals per physician order 5 x weekly x 4 weeks, 3 x weekly x 4 weeks, twice weekly x 4 weeks then weekly and PRN as indicated. DON/designee to conduct ongoing quality monitoring through resident interview and observation to ensure snacks are provided upon request 3 x weekly x 2 weeks, twice weekly x 2 weeks then weekly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months then quarterly and PRN as indicated and modified based on findings.
Failure to Protect Residents from Abuse by CNA
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse by a staff member, Staff J, CNA, towards two residents, Resident #11 and Resident #12. On December 20, 2024, Staff J was witnessed by another CNA, Staff I, slapping the residents on their legs, sides, and buttocks during care. Despite witnessing the abuse, Staff I did not report the incident until three days later, leaving other residents at risk of further abuse. The delay in reporting was attributed to Staff I's fear of being targeted due to past personal trauma. Resident #11, who was admitted with severe intellectual disabilities, quadriplegia, epilepsy, legal blindness, scoliosis, and gastrostomy status, was non-verbal and dependent on staff for all care needs. Resident #12, with a history of traumatic brain injury, psychosis, and muscle weakness, was also non-verbal and required substantial assistance for mobility and hygiene. Both residents were placed on 15-minute checks following the delayed report of abuse, as indicated by a sign observed in the facility. Interviews with facility staff revealed a culture of fear and reluctance to report abuse, as evidenced by Staff K, Door Monitor, who had previously witnessed Staff J's abusive behavior but did not report it. The Nursing Home Administrator confirmed the incident and stated that Staff J was suspended and later terminated. The facility's abuse prevention policy, which mandates immediate reporting and thorough investigation of abuse, was not adhered to, resulting in a failure to protect vulnerable residents from harm.
Failure to Report Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an incident of verbal and physical abuse by a Certified Nursing Assistant (CNA) towards two residents. The incident involved Staff J, CNA, who was reported to have been rough and abusive while assisting with the care of two residents. Staff I, CNA, who was present during the incident, reported that Staff J slapped the residents multiple times, leaving a handprint on one of them. Despite witnessing the abuse, Staff I did not report the incident immediately due to fear of retaliation, and the incident was only reported to the Nursing Home Administrator (NHA) three days later. The residents involved in the incident had significant medical conditions and were highly dependent on staff for their care. One resident had severe intellectual disabilities, quadriplegia, and was legally blind, while the other had severe cognitive impairment and required substantial assistance for mobility and hygiene. Both residents were non-verbal, making them particularly vulnerable to abuse. The delay in reporting the incident meant that the abuse was not addressed promptly, potentially compromising the residents' safety and well-being. The facility's policy required immediate reporting of any suspected abuse to management, but this protocol was not followed. Staff I, CNA, initially attempted to inform a nurse but was unsuccessful and instead reported the incident to a door monitor, who corroborated the abusive behavior of Staff J. The NHA was eventually informed of the incident, and law enforcement and state agencies were notified. However, the delay in reporting and the failure to adhere to the facility's abuse reporting policy constituted a significant deficiency in the facility's operations.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue was the failure to report rashes affecting four residents to the local health department and to ensure appropriate testing for a possible contagious epidermal condition. The Director of Nursing/Infection Preventionist (DON/IP) was unaware that the residents were being treated with medication for scabies, and the facility did not track these cases on their infection map. The DON/IP admitted to not reporting the rashes because they were not classified as scabies, despite the residents receiving treatment for it. Another deficiency involved a resident with a bloodborne pathogen who had a blood-stained pillowcase that was not changed promptly. Observations revealed that the pillowcase remained stained with blood for an extended period, posing an infection control concern. Interviews with the Nursing Home Administrator (NHA), DON/IP, and staff confirmed that the blood-stained linen should have been changed immediately to prevent infection risks. Additionally, the facility did not adhere to infection control practices during medication administration. A Licensed Practical Nurse (LPN) was observed placing a glucometer back into the medication cart without cleaning or sanitizing it after use. The DON/IP confirmed that glucometers should be cleaned with bleach wipes after each use, but this protocol was not followed. These lapses in infection control practices highlight significant deficiencies in the facility's infection prevention and control program.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its residents, as evidenced by multiple observations of unsanitary conditions in resident rooms, bathrooms, and common areas. Observations revealed the presence of petrified worms and lizards, brown and black stains on floors and walls, and significant debris accumulation in various locations. Bathrooms were particularly affected, with brownish stains and buildup on toilets, sinks, and floors, as well as cracked and uncleanable surfaces. The presence of exposed wires on bed remotes further highlighted the unsafe conditions. Interviews with the Maintenance Director and Nursing Home Administrator confirmed the unsatisfactory state of cleanliness and safety in the facility. The Maintenance Director acknowledged the need for cleaning rather than just floor maintenance, while the Nursing Home Administrator admitted awareness of the need to replace non-cleanable surfaces and ensure daily cleaning of resident rooms. Despite having policies in place for cleaning procedures, the facility failed to adhere to these standards, resulting in the observed deficiencies. The report includes photographic evidence of the unsanitary conditions, reinforcing the findings. The facility's failure to provide a clean and safe environment compromised the residents' right to a homelike setting, as mandated by regulations. The observations spanned several days, indicating a systemic issue rather than isolated incidents, and involved multiple resident rooms, bathrooms, and common areas, underscoring the widespread nature of the problem.
Controlled Medication Discrepancies in Medication Carts
Penalty
Summary
The facility failed to ensure accurate accountability and storage of controlled medications in two out of three medication carts inspected. During an observation, discrepancies were found in the narcotic count of the East Wing Carts 1 and 2. Specifically, there was a loose pill in the narcotic box, and several discrepancies in the controlled substance records for Clonazepam, Oxycodone, Tramadol, and Hydrocodone/APAP tablets. Additionally, a card containing Tramadol tablets was found for a resident who had already been discharged, indicating a failure to remove discharged narcotics from the cart. Interviews with staff revealed that the LPN responsible for the medication carts admitted to not signing out medications when administered due to a hectic morning. The LPN also stated that discharged narcotics should have been removed, but this task was overseen by the DON, who was unaware of the narcotic medication card from a discharged resident. The facility's policies on controlled substances and medication storage require compliance with laws and regulations, including immediate documentation after administration and secure storage of medications, which were not adhered to in this instance.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 28.57% based on observations of medication administration. During the survey, 35 medication administration opportunities were observed, resulting in ten errors involving four residents. These errors included incorrect dosages, failure to follow proper medication administration procedures, and inappropriate handling of medications. One incident involved a Licensed Practical Nurse (LPN) administering medications to a resident with a gastric tube. The LPN dispensed 5 mL of Levetiracetam instead of the prescribed 10 mL and failed to administer Ferrous Sulfate and Calcium as ordered via the PEG-Tube. Another error was observed when a Registered Nurse (RN) failed to administer Thiamine HCl to a resident as per the medication administration record. Additionally, the RN crushed extended-release medications, which is contraindicated, and mixed them with pudding for another resident. Further errors were noted when an LPN did not prime an insulin pen before administering insulin to a resident, contrary to the manufacturer's instructions. Interviews with the Director of Nursing, Medical Director, and Pharmacist confirmed that the facility's practices did not align with proper medication administration guidelines, contributing to the high error rate.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for three residents during assisted dining. Resident #8, diagnosed with amyotrophic lateral sclerosis, required staff assistance with eating. On a specific day, a CNA was observed standing while assisting the resident with their meal, despite a chair being available in the room. The CNA acknowledged the oversight and mentioned having received education on the proper procedure, which involves sitting at eye level with the resident during meal assistance. Both the Director of Nursing and the Nursing Home Administrator confirmed that the expectation was for staff to sit at eye level when assisting residents with meals. Additionally, Resident #3 was observed being fed by a CNA who was standing, and Resident #27 was assisted by a CNA who initially stood and then sat on the resident's bed, which is against protocol. The CNA admitted to sitting on the bed and cited a lack of available chairs as the reason. The facility's policy on Resident Rights emphasizes the importance of a dignified existence and being treated with respect, which was not upheld in these instances.
Failure to Provide Written Notification for Room Change
Penalty
Summary
The facility failed to honor a resident's right to receive written notification for a room change before the change was made. Resident #51, who had a moderately impaired mental status with a BIMS score of 11, was moved from her original room to a new room without prior notice or explanation. The resident expressed confusion about the move, stating she was not given an opportunity to see the new room or understand the reason for the change. The facility's records showed no documentation regarding the move or the reason for the room change. Interviews with facility staff revealed a lack of communication and documentation regarding the room change. The Social Services Director stated that the process for a room change involves notifying the resident and their representative, but there was no documentation in the room change binder. The Director of Nursing admitted to moving the resident without informing her of the reason, as he was waiting for information from the Health Department. The facility's policy requires advance notice and documentation of room changes, which was not followed in this instance.
Failure to Provide Wound Care Per Physician Orders
Penalty
Summary
The facility failed to provide wound care according to physician orders for a resident with a wound on the right shoulder. Observations revealed blood stains on the resident's pillow, and the resident confirmed the stains were from her shoulder wound. The wound was described as red, raw, and bloody, and was open to the air. The resident had a history of chronic viral hepatitis C, anoxic brain damage, seizures, anxiety disorder, obsessive-compulsive disorder, and bipolar disorder, with a moderate cognitive impairment score. The facility's Treatment Administration Record (TAR) showed missed wound care treatments on several occasions, specifically on the 19th, 20th, and 23rd of the month. The care plan did not include any focus, goals, or interventions for the resident's shoulder wound. Interviews with staff, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), confirmed the absence of documented treatments and the lack of a current care plan addressing the wound. The facility's policy required treatment per physician order with documentation in the medical record, which was not followed. The attending physician expected the nurses to adhere to the wound care orders, and the wound physician recommended covering the wound with a hydrocolloid dressing. However, the facility did not consistently apply the dressing or document the care provided, leading to the deficiency.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure the proper storage of respiratory equipment for two residents, leading to unsanitary conditions. Resident #34's oxygen tubing was observed on her bedside table and the floor, not stored in a sanitary manner. The resident, who uses oxygen as needed due to morbid obesity, expressed a need for oxygen during the observation. The care plan for Resident #34 indicated the need for oxygen therapy related to obesity, with specific interventions for monitoring and documenting respiratory distress. Interviews with staff revealed that the tubing and cannula should be stored in a bag when not in use, but there was no policy in place regarding the storage of respiratory equipment. Resident #39 was observed with oxygen tubing connected to an oxygen concentrator, with a piece of tape dated 9/16/2024, indicating the tubing had not been changed as per the physician's order. The facility's policy required oxygen tubing to be changed weekly or as needed when soiled. Staff interviews confirmed the tubing change process was not clearly understood, contributing to the deficiency. The lack of adherence to the facility's policy and physician orders for changing and storing respiratory equipment resulted in unsanitary conditions for both residents.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and security of medications in several areas, including the East medication storage room, Reflection Hallway treatment cart, and multiple medication carts. During observations, a cabinet in the Reflection Hallway was found unlocked with a resident's prescribed medication inside. Staff D, LPN/UM, acknowledged the cabinet should be locked but could not explain why the medication was there. Additionally, a PPE storage bin outside resident rooms contained an open box of Hydrocortisone Acetate 1% Cream packets. In the East Wing medication storage room, the narcotic box inside the refrigerator was unlocked, and the Director of Nursing (DON) struggled to find the correct keys to secure it, revealing that only one nurse, who works infrequently, had access to the keys. Further observations revealed issues with medication carts. The East Cart 2 had two unlabeled insulin pens and a loose pill in the narcotic box. Staff H, LPN, confirmed these items should be labeled and the loose pill destroyed. The cart's surface was also found with a liquid and white powdered substance. In the [NAME] Wing, Staff I, RN, found loose pills in the medication cart's drawer, which were not supposed to be there. Additionally, East Cart 2 was left unlocked and unattended, with numerous staff and residents passing by, until the Nursing Home Administrator intervened. The facility's policy mandates that all drugs and biologicals be stored securely and that medication carts not be left unattended, which was not adhered to in these instances.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to honor meal preferences for a resident with a primary diagnosis of amyotrophic lateral sclerosis, who was on a regular diet with pureed texture and nectar/mild thick consistency. The resident, who was cognitively intact with a BIMS score of 13 out of 15, had a documented dislike for green beans. Despite this, the resident was served green beans during lunch, which was confirmed by both the resident and Staff A, a Certified Nursing Assistant (CNA). The resident also expressed a dislike for the spicy sausage served and was not offered an alternative meal option. Interviews with Staff A, the Certified Dietary Manager (CDM), the Director of Nursing (DON), and the Nursing Home Administrator (NHA) revealed a breakdown in the facility's process for honoring meal preferences. Staff A admitted to not checking the resident's meal ticket for dislikes and failing to offer an alternative. The CDM acknowledged that the process to identify disliked items was not followed, resulting in the resident being served an unwanted meal. Both the DON and NHA confirmed that the resident should have been offered an alternative meal, and the dietary staff should have adhered to the resident's documented meal preferences.
Lack of Communication and Documentation in Hospice Services
Penalty
Summary
The facility failed to ensure hospice services were provided in accordance with accepted professional standards and principles due to a lack of communication and documentation in the medical record for a resident. The resident, who was re-admitted with early onset Alzheimer's disease and other co-morbidities, had a physician order for hospice care due to advanced dementia. However, there was no documentation of hospice services in the resident's progress notes or care plan, despite the Minimum Data Set indicating hospice care was being given. Interviews with facility staff revealed communication issues between the facility and the hospice provider. The Registered Nurse stated that communication with hospice only occurred if there was a change in the resident's condition. The Director of Nursing (DON) mentioned that the hospice nurse did not check out with her or leave any notes, which was a consistent problem. The facility's policy required a coordinated plan of care with hospice, including communication and documentation, which was not followed in this case.
Latest citations in Florida
Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
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