Lake Placid Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Placid, Florida.
- Location
- 125 Tomoka Blvd S, Lake Placid, Florida 33852
- CMS Provider Number
- 105455
- Inspections on file
- 27
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Lake Placid Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, mood disorder, depression, and anxiety, and with severe cognitive impairment, was started on and had dose changes to psychotropic medications (Haldol and Depakote) without prior notification to or consent from the Health Care Surrogate (HCS). The HCS reported not being informed before these medications were implemented and was upset about the lack of communication. An LPN and the unit manager described a facility process requiring prior HCS notification, risk discussion, and a signed psychotropic consent form, but acknowledged that the resident received multiple doses of Depakote and a Haldol injection before any psychotropic consent form was signed. MAR and progress notes confirmed administration of these medications and later documentation of consent, while the DON confirmed that consent should have been obtained and that there was no documentation showing the family was notified before the psychotropic medications were initiated.
A resident with multiple chronic conditions experienced a decline in appetite, responsiveness, and continence over several days, which was observed and reported by a CNA but not promptly assessed by nursing staff. Despite family concerns and requests for evaluation, no timely assessment or vital signs were documented by LPNs or the DON. The resident was eventually sent to the hospital and admitted for sepsis and dehydration, with facility records showing gaps in monitoring, documentation, and adherence to care plan interventions.
Multiple residents did not receive meals that accommodated their documented allergies, intolerances, and dietary preferences. One resident with a vegetarian diet repeatedly received meat, resulting in emotional harm and discharge against medical advice. Another resident with a shellfish allergy was served shrimp, and two others did not receive correct meal portions or were served foods they could not tolerate. These failures were confirmed through observations, interviews, and record reviews, showing a breakdown in the facility's dietary service processes.
The facility did not ensure accurate and complete PASARR Level I and II screenings for multiple residents with diagnoses of serious mental illness or intellectual disability. Several residents were admitted with psychiatric and behavioral health conditions, but their PASARR documentation was incomplete, missing, or not updated to reflect their diagnoses, and required Level II evaluations were not conducted. The process for managing PASARRs was inconsistent, with gaps in staff access and oversight, resulting in noncompliance with regulatory requirements.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Staff failed to consistently perform hand hygiene between tasks such as passing meal trays, assisting residents, and handling garbage, and did not offer or assist residents with hand hygiene prior to meals. Several staff members had fingernails and hair styles not in compliance with facility policy and CDC guidelines, and one CNA used a personal cloth to wipe perspiration while continuing to assist with meal service without hand hygiene. Residents with moderate cognitive impairment were not offered hand hygiene before meals, and staff did not always follow hand hygiene protocols during medication administration and meal service.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
The facility did not consistently log or address grievances raised by residents and their representatives, including concerns about staff behavior, call light response times, and dietary services. Despite staff awareness of the grievance process, concerns were not documented or followed up on, and residents did not receive communication regarding the resolution of their issues, contrary to facility policy.
The facility did not ensure that two residents and their representatives received proper documentation and notification regarding transfer or discharge. For one resident with severe cognitive impairment and multiple mental health diagnoses, there was no record of notification or the required transfer/discharge notice when transferred to the hospital. For another resident with cardiac and vascular conditions, discharge documentation was incomplete and unsigned, and there was no evidence that the required notice or discharge information was provided.
Surveyors found multiple safety deficiencies, including an unsecured and hot steam table accessible to residents, restrooms without emergency call cords, and unlocked cabinets containing hazardous chemicals. Additionally, a resident with behavioral disturbances and a history of aggression was left unsupervised despite orders for 1:1 supervision. The DON and staff confirmed these lapses in safety and supervision.
Surveyors identified that the facility's medication administration practices resulted in a medication error rate of 5 percent or greater, exceeding the regulatory limit.
Surveyors found that medication carts and storage areas contained expired, undated, and loose medications, including unlabeled vials and open bottles without dates. Controlled substances were not properly secured, with narcotic boxes attached to removable shelves and emergency kits not affixed. CPR carts containing glucose gel were left unlocked, and medications were observed unsecured on carts and at residents' bedsides, even though no residents were approved for self-administration. Staff interviews confirmed these lapses despite facility policies requiring secure and proper medication storage.
Residents on one unit did not receive their meal trays at the same time, resulting in some watching others eat or waiting extended periods for their food. One resident consumed another's drink and ice cream while unsupervised, and another remained at the table with a dirty tray long after the meal. Staff interviews revealed a lack of training on serving meals together, and a nurse administered eye drops at the dining table, all of which failed to uphold resident dignity.
A resident was not adequately prepared for a safe transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences, resulting in a deficiency in care planning and transition.
Three residents did not receive adequate assistance with ADLs, including grooming, nail care, haircuts, and shaving. One resident had matted hair and overgrown nails, another was unable to get a haircut due to the absence of a beautician, and a third had unaddressed facial hair and inconsistent shaving assistance. Staff interviews and documentation revealed lapses in providing and recording these essential care services, despite residents' dependence on staff and facility policy requirements.
A licensed pharmacist did not complete the required monthly drug regimen review, including the medical chart, and the facility failed to follow its own policies for reporting irregularities found during the review.
A resident with moderate cognitive impairment and multiple diagnoses expressed a desire to transfer to another facility, but staff did not document her request or any follow-up discussions. The facility failed to honor and facilitate the resident's right to self-determination, as required by policy.
The facility failed to maintain a proper grievance process for three residents, with issues including missing documentation, unresolved grievances, and lack of follow-up. A resident's missing clothing was not properly documented, another resident's missing money was not deposited into their trust account, and a third resident's complaint about cold meals was not resolved. The Social Service Director admitted to not addressing grievances comprehensively in QAPI meetings.
A resident's personal funds were not returned within 30 days of discharge. The facility failed to document and resolve a grievance regarding missing money. The Business Office Manager confirmed that $11 remained in the safe, and $4 was given to the resident without proper documentation.
Failure to Obtain HCS Consent Prior to Psychotropic Medication Changes
Penalty
Summary
The deficiency involves the facility’s failure to inform and obtain consent from a resident’s Health Care Surrogate (HCS) prior to initiating and changing psychotropic medications. The resident, who had diagnoses including other specified mood disorders, unspecified dementia with behavioral disturbance, major depressive disorder, and anxiety disorders, was admitted in 2025 and had severe cognitive impairment as evidenced by a BIMS score of 3 on a later MDS. The HCS reported that the facility did not communicate medication changes before they were implemented, specifically noting the initiation of Haldol and Depakote after the resident exhibited behavioral issues. The HCS expressed being upset that these changes were not communicated in advance. Interviews with staff confirmed that facility practice and expectation were that the HCS should be notified and consent obtained before starting psychotropic medications. Staff A, an LPN, stated that the unit manager was supposed to notify the family before starting psych medications and that there was no reason not to notify the HCS prior to initiating such medications; Staff A also stated the HCS had refused psychotropic medication for the resident. Staff B, an LPN and Unit Manager, described the process for obtaining psychotropic consent, including calling the HCS, explaining risks, documenting verbal consent on a psychotropic medication form, and uploading the form and a progress note to the medical record. However, Staff B acknowledged that Haldol was ordered on 04/11/2025 and administered on 04/26/2025, and that Depakote had been administered and later dose-adjusted in April 2025, without a psychotropic consent form signed prior to those administrations. Record review corroborated that the resident received multiple psychotropic medications before documented consent was obtained. The MAR showed administration of divalproex sodium 125 mg from 04/01/2025 through 04/13/2025, Depakote ER 250 mg from mid- to late April 2025, Depakote ER 500 mg starting 04/28/2025, and a Haldol injection on 04/26/2025. A psychotropic medication administration disclosure/consent form was dated 04/28/2025, and Staff B stated this was the first psychotropic consent form seen for Depakote, acknowledging it should have been signed before the resident received Depakote and Haldol. Progress notes documented behavioral issues and the use of Haldol for severe agitation, as well as a late entry note on 04/28/2025 indicating that a behavioral health provider assessed the resident and that a family member gave consent for medication at that time. The DON confirmed that consent should have been obtained for Haldol and Depakote prior to administration, that families were typically contacted before psychotropic medications were given, and that there was no documentation in the record confirming that the provider had notified the family before the medications were started.
Failure to Timely Assess and Respond to Change in Condition
Penalty
Summary
The facility failed to identify and assess a change in condition in a timely manner for a resident with multiple complex diagnoses, including multiple sclerosis, adult failure to thrive, a history of urinary tract infections, cystic liver disease, dysphagia, and abnormal weight loss. The resident was noted by a CNA to have decreased appetite and changes in behavior over several days, including being less responsive and not exhibiting her usual complaints during care. Despite these observations, the CNA's concerns were not promptly acted upon by nursing staff, and no documented assessments or vital signs were recorded during the period when the resident's condition was changing. On the day of the incident, both the CNA and the LPN observed that the resident was more tired than usual and not at her baseline. The LPN attributed the resident's fatigue to possible poor sleep and did not perform an assessment or obtain vital signs. The unit manager and the DON were also made aware of the resident's change in condition, but again, no assessment or vital signs were documented. The family was notified and requested a urinalysis, which was ordered, but staff were unable to obtain a sample. Later in the day, the resident was found to be unresponsive and hot to the touch, at which point she was sent to the hospital and subsequently admitted for sepsis and dehydration. The facility's documentation revealed a lack of timely and thorough assessment following reports of a change in condition, as well as gaps in monitoring and documentation of the resident's nutritional status and weight trends. The care plan for the resident included interventions for monitoring for signs of malnutrition, dehydration, and infection, but these were not effectively implemented. Facility policies and job descriptions require prompt assessment and documentation of changes in condition, but these were not followed in this case, resulting in a failure to provide necessary care and monitoring.
Failure to Honor Dietary Allergies, Intolerances, and Preferences
Penalty
Summary
The facility failed to ensure that food allergies, intolerances, and dietary preferences were honored for four out of five residents reviewed for nutritional services. One resident, who was a vegetarian with a moderate cognitive impairment, repeatedly received meals containing meat despite clear documentation of her dietary restrictions and multiple grievances filed on her behalf. The resident and her family communicated these concerns to staff, and the care plan specifically noted her vegetarian status and food preferences. Despite these measures, the resident continued to receive incorrect meals, leading to emotional distress and ultimately her discharge against medical advice. The facility was unable to provide a vegetarian menu to surveyors upon request, and meal tickets did not consistently reflect the resident's preferences or the interventions taken by dietary staff. Another resident with a documented shellfish allergy was served shrimp, contrary to the dietary order and meal ticket instructions. Staff interviews revealed that the process for assembling meal trays involved multiple checks, but the system failed, resulting in the resident being exposed to an allergen. The resident had a history of moderate allergic reactions to shellfish, and the care plan included clear instructions to avoid exposure. Staff confirmed that the resident had previously experienced a reaction to shrimp, and the allergy was documented in the medical record. Despite this, the resident was served shrimp, and the incident was only discovered after the meal was delivered. Additional deficiencies included a resident who was supposed to receive large portions but consistently received standard portions, and another resident with lactose intolerance and diabetes who was repeatedly served dairy products and sweets. In both cases, the residents' dietary needs were clearly documented in their records and on meal tickets, but the kitchen staff failed to provide the correct meals. These failures were confirmed through direct observation, interviews with residents and staff, and review of dietary documentation.
Failure to Complete Accurate PASARR Screenings for Residents with Mental Illness or Intellectual Disability
Penalty
Summary
The facility failed to ensure that Level I and Level II Preadmission Screening and Resident Review (PASARR) screenings were accurate and complete for 12 out of 14 sampled residents. Multiple residents were admitted with diagnoses such as bipolar disorder, schizoaffective disorder, major depressive disorder, generalized anxiety disorder, and other serious mental illnesses, yet their PASARR Level I screens either did not reflect these diagnoses or failed to indicate the need for a Level II evaluation. In several cases, the PASARR forms were incomplete, blank, or missing critical information, and no Level II PASARR was conducted despite qualifying diagnoses and evidence of functional impairment due to mental illness. Interviews with the Director of Nursing (DON) revealed that the facility's process for handling PASARR screenings was inconsistent and lacked oversight. The DON confirmed that PASARRs were not always available upon admission and that the responsibility for completing and updating PASARRs was assigned to social services staff, who were not consistently present or available. The DON also acknowledged that she did not verify the accuracy or completion of PASARRs and that there was no current access to the PASARR system by facility staff, resulting in delays or omissions in required screenings and referrals for Level II evaluations. The medical records reviewed showed that residents with significant psychiatric and behavioral diagnoses were not properly identified in the PASARR process, and in some cases, residents were receiving psychotropic medications and behavioral interventions without the required PASARR documentation. Facility policy required prompt referral for Level II PASARR when a serious mental disorder or intellectual disability was identified, but this was not consistently followed. The lack of accurate and timely PASARR screenings led to residents with serious mental illness or intellectual disability not being properly evaluated as required by federal regulations.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Follow Infection Control and Hand Hygiene Practices During Meal and Medication Service
Penalty
Summary
Multiple observations and interviews revealed that staff did not consistently follow infection prevention and control practices during meal service and medication administration. Staff members, including CNAs, the Activities Director, and dietary staff, were observed failing to perform hand hygiene between tasks such as passing meal trays, assisting residents, handling garbage, and touching their faces. In several instances, staff did not offer or assist residents with hand hygiene prior to meals, despite residents expressing a desire for such assistance. Additionally, hand sanitizer dispensers were found to be empty or inaccessible to residents who required help. Further deficiencies were noted in personal hygiene practices among staff. Several staff members, including CNAs and nurses, were observed with fingernails extending beyond the facility's policy limits and CDC recommendations, and with hair styles that could interfere with care. One CNA was seen repeatedly using a personal cloth to wipe perspiration from their face and then continuing to assist with meal service without performing hand hygiene. Staff interviews confirmed a lack of adherence to hand hygiene protocols, particularly after touching their faces or other potentially contaminated surfaces. The facility's own policies and CDC guidelines require hand hygiene before and after resident contact, after glove use, and after contact with potentially contaminated surfaces. However, staff interviews and direct observations indicated that these protocols were not consistently followed. Residents with moderate cognitive impairment were not offered hand hygiene before meals, and staff did not always perform hand hygiene as required by policy during medication administration and meal service. These lapses were confirmed by both staff and residents during interviews.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Address and Document Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were properly addressed and documented, as required by policy and regulation. Over a six-month period, concerns raised during resident council meetings, such as issues with cold food, call light response times, and dietary services, were not consistently logged as grievances, with only one grievance documented for the entire period. The Activities Director reported transcribing concerns from resident council meetings and submitting them as grievances to Social Services or the Nursing Home Administrator, but there was no evidence of follow-up or resolution communicated back to the resident council. Individual residents and their representatives also reported grievances that were not documented or resolved. One resident, who was cognitively intact and had hemiplegia, reported being treated rudely by a CNA and discussed the incident with an LPN and a Unit Manager. However, there was no record of a grievance being filed for this incident. Another resident's representative reported repeatedly raising concerns about call light response times to various staff members without receiving any resolution or follow-up. Similarly, a third resident's representative stated that concerns discussed with staff and the administrator were not addressed or followed up on, and no grievances were logged for these issues. Interviews with staff responsible for grievance management confirmed that grievances were not consistently logged or tracked for the concerns raised by residents and their representatives. The Social Services staff member acknowledged that grievances should have been written for the incidents described but were not. The facility's grievance policy outlines a process for logging, investigating, and resolving grievances, including prompt follow-up and written decisions, but this process was not followed in the cases reviewed. As a result, the facility did not ensure that residents' rights to voice grievances without discrimination or reprisal were honored, nor did it make prompt efforts to resolve grievances as required.
Failure to Provide Required Transfer/Discharge Documentation and Notification
Penalty
Summary
The facility failed to properly document and notify residents and their representatives regarding transfers or discharges, as required. For one resident with severe cognitive impairment and multiple mental health diagnoses, there was no documentation in the medical record of notifications to the resident or their representative when the resident was transferred to the hospital. The required Nursing Home Transfer and Discharge Notice (AHCA Form 3120-0002) was not found in the resident's records, nor was there evidence that the notice was given or mailed to the resident or their representative. Interviews with facility staff confirmed that the notice was not provided to residents or their representatives, but only faxed to the Ombudsman monthly. Another resident, with a history of cardiac and vascular conditions, was discharged home, but the discharge summary and instructions were incomplete and unsigned. The discharge documentation lacked essential information such as the primary physician, contact information for home health and medical equipment providers, and details on appointments, medication reconciliation, and disease management. There was also no evidence that the required transfer and discharge notice was present in the resident's records or that any information was provided to the resident upon discharge, as confirmed by the DON after reviewing the records.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
The facility failed to maintain a safe environment for residents by not securing accident hazards and not providing adequate supervision. Surveyors observed an unsecured and hot steam table in the North Wing Dining Room, with both entry doors open and unlocked, allowing residents unrestricted access to the steam table during meal service. Staff interviews confirmed that the steam table remained on and hot throughout breakfast and lunch, and the door meant to separate residents from the steam table was not consistently closed or locked. Additionally, two restrooms in the main hallway were found to lack emergency call cords near the toilets, despite being accessible to residents. Further deficiencies were identified regarding the storage of hazardous chemicals. On the Happy Trails unit, an unlocked cabinet in the dining/activity room contained a spray bottle of odor eliminator, and in the North Wing dining room, another unlocked cabinet contained a bottle of ant, roach, and fly spray. Both cabinets were accessible to residents at the time of observation. The DON acknowledged that these cabinets should have been locked to prevent resident access to hazardous substances. The facility also failed to provide required one-to-one supervision for a resident with a history of behavioral disturbances, including aggression and exit-seeking behaviors. Staff assigned to supervise the resident left the resident unattended in their room, contrary to physician orders and the resident's care plan, which called for continuous one-to-one supervision. The DON confirmed that staff should have remained within sight and close enough to intervene as needed. The resident's record indicated a history of agitation, aggression, and a prior incident of resident-to-resident abuse.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors among residents. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Medication Storage and Security Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of medications throughout the facility. Observations revealed that medication carts contained expired, undated, and loose medications, including vials of Albuterol/Ipratropium nebulizer medication not stored in their original packaging, an unlabeled vial without a resident name, and open bottles of Latanoprost ophthalmic drops and liquid protein that were not dated. Additional findings included loose pills and expired medications in medication carts, as well as expired Bisacodyl suppositories and vancomycin IV bags in the medication storage room. Staff interviews confirmed that nurses are responsible for cleaning their own carts, but expired and loose medications were still present. Controlled substances were not properly secured, as locked narcotic boxes in medication refrigerators were attached to removable shelves, making them unremovable as required. An emergency drug kit containing Lorazepam, a controlled substance, was also not securely attached in the refrigerator. CPR carts on two halls were found unlocked and contained glucose gel, and staff confirmed that all nurses have keys to these carts. Additionally, medications were observed left unsecured on top of medication carts and in resident rooms, including antacid tablets and an antibiotic vial at bedside, despite no residents being approved for self-administration of medications. Facility policy requires all drugs and biologicals to be stored in locked compartments and under proper conditions, with controlled substances in separately locked, permanently affixed compartments. The policy also mandates that medications must be under direct observation or locked during medication passes, and that expired or unused medications are to be routinely removed. Despite these policies, surveyors found multiple instances where medications were not properly labeled, stored, or secured, and staff interviews confirmed lapses in adherence to these protocols.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to maintain resident dignity during meal service on the East Wing, as evidenced by multiple observations and staff interviews. Residents seated together at dining tables did not receive their meal trays at the same time, resulting in some residents watching others eat or waiting extended periods for their own meals. In one instance, a resident who was asleep at the table awoke and consumed another resident's drink and ice cream while no staff were present in the dining room. Another resident was observed sitting with a half-eaten lunch and a blanket over his head, still at the table more than an hour after the meal had ended. Additionally, a resident was seen waiting outside her room for her meal tray while her roommate had already received hers, and other residents at a table received their trays several minutes apart. Staff interviews revealed a lack of training and awareness regarding the importance of serving meals simultaneously to residents seated together. CNAs and nursing staff indicated that meal trays are delivered based on room order and not coordinated for those dining together, and the kitchen staff were not informed about which residents eat in the dining room. The DON acknowledged that staff should be aware of the need to serve meals together and agreed that the observed practices were dignity concerns. Furthermore, a nurse was observed administering eye drops to a resident at the dining table, which was confirmed by the DON as inappropriate. The facility's policy on promoting and maintaining resident dignity was not followed, as staff actions did not ensure respect and dignity during meal times.
Failure to Ensure Safe and Individualized Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed, resulting in a deficiency related to resident care planning and transition.
Failure to Provide Adequate ADL Assistance for Grooming and Hygiene
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were completed for three residents, specifically in the areas of grooming, nail care, haircuts, and showers. One resident was observed with unkempt and matted hair, overgrown yellow fingernails with black debris, and expressed a desire for assistance with hair brushing and nail trimming. This resident was assessed as cognitively intact and dependent on staff for bathing and personal hygiene, with a care plan indicating the need for staff assistance in these areas. Despite these needs, the resident's grooming and hygiene were not adequately maintained. Another resident reported dissatisfaction with the length of their hair and the lack of available haircuts, noting that a beautician had not been present for several weeks. Staff interviews confirmed that the facility previously had a beautician who provided regular haircuts, but due to the beautician's absence, hair care services had lapsed. The process for residents to request haircuts was described, but it was also acknowledged that no beautician was currently available, and efforts to secure a replacement were ongoing. A third resident was observed with significant facial hair and stated a preference for being shaved, which was not consistently provided. Documentation and interviews revealed inconsistencies in the provision and recording of shaving assistance, with some shower logs lacking information on whether shaving was completed or if refusals occurred. The resident's care plan and progress notes did not address shaving needs or refusals, despite the resident's moderate cognitive impairment and dependence on staff for personal hygiene. The facility's ADL policy requires that residents unable to perform ADLs receive necessary services to maintain grooming and hygiene, but these requirements were not met for the residents reviewed.
Failure to Ensure Monthly Pharmacist Drug Regimen Review and Irregularity Reporting
Penalty
Summary
A licensed pharmacist did not perform a monthly drug regimen review, including a review of the medical chart, as required. The facility also failed to follow its developed policies and procedures for reporting irregularities identified during the drug regimen review process. This deficiency was identified during the survey based on the facility's lack of compliance with established guidelines for pharmacist review and reporting.
Failure to Support Resident's Choice to Transfer
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's right to self-determination by not supporting her expressed choice to transfer to another facility. The resident, who had a history of protein-calorie malnutrition, bipolar disorder, mood disorder, opioid dependence, and generalized anxiety disorder, communicated her desire to move to another facility but reported that her requests were ignored and not acted upon. The resident had a moderate cognitive impairment, as indicated by a BIMS score of 10 out of 15. There was no documentation in her progress notes or the facility's grievance log regarding her request or any follow-up actions taken by staff. Interviews with the Social Services Assistant revealed that although she was aware of the resident's wish to transfer and had discussed it with her, she did not document the conversation or any change in the resident's wishes. The facility's policy requires informing residents of their rights and documenting relevant information, but there was no evidence that the resident's request or subsequent discussions were recorded. This lack of documentation and follow-up resulted in the facility failing to promote and facilitate the resident's right to make choices about her care and living arrangements.
Deficient Grievance Process in LTC Facility
Penalty
Summary
The facility failed to ensure a functioning grievance process for three residents, as evidenced by the lack of proper documentation and follow-up on grievances. For Resident #1, the facility's grievance log showed two grievances regarding hydration preference and room cleanliness, both marked as resolved. However, a concern about missing clothing items was not properly documented or resolved. The Social Service Director (SSD) had only a post note with no specific details, and the missing items list was incomplete. The SSD offered $100 to the family verbally, but there was no documentation of this offer being made or accepted. Resident #2's grievance involved missing money and clothing items. The grievance log had incomplete documentation, lacking details about the person making the complaint and whether the grievance was resolved. The SSD confirmed that the money was replaced, but the Business Office Manager (BOM) revealed that the money was never deposited into the resident's trust account and remained in the safe. The BOM also noted discrepancies in the documentation of the money returned to the resident. For Resident #9, the grievance log showed two grievances: one about cold meals and another about broken call lights. The resolution for the cold meal grievance was not documented, and the resident confirmed that the issue persisted. The call light grievance lacked documentation of who investigated it, and while some corrective actions were noted, the resident reported no follow-up on the cold meal issue. The SSD admitted to not discussing grievances comprehensively in Quality Assurance and Performance Improvement (QAPI) meetings, indicating a systemic issue in handling grievances effectively.
Failure to Return Resident's Personal Funds Post-Discharge
Penalty
Summary
The facility failed to convey personal funds deposited with the facility within 30 days of discharge for a resident. The resident was admitted to the facility and subsequently discharged on a specified date. However, a balance of $11.00 in the resident's personal trust account was not returned. A grievance was filed regarding the missing money, but the grievance form lacked documentation of the person making the complaint, their relationship to the resident, and whether the grievance had been resolved. The Social Services Director (SSD) acknowledged the grievance but did not have documentation of the amount of money involved. The Business Office Manager (BOM) presented a receipt for $15.00 intended for the resident's trust account, which was never deposited. Instead, the money remained in the safe, and $4 was given to the resident without proper documentation or signatures. The BOM confirmed the remaining $11 was still in the safe, and the discrepancy was not resolved. The Nursing Home Administrator (NHA) indicated plans to initiate training on handling missing items and grievances, but this was not part of the deficiency itself.
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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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