Lake Wales Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Wales, Florida.
- Location
- 730 N Scenic Hwy, Lake Wales, Florida 33853
- CMS Provider Number
- 106069
- Inspections on file
- 21
- Latest survey
- June 24, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lake Wales Health And Rehabilitation Center during CMS and state inspections, most recent first.
A deficiency occurred when a resident's room remained excessively hot, with temperatures near 90°F, due to an unrepaired rooftop A/C unit. The resident, who was nonverbal and medically complex, experienced physical discomfort for about a month while staff and maintenance were aware of the issue but did not routinely monitor or document room temperatures. Leadership lacked a formal process for temperature checks or maintenance reporting, and no policies were provided to ensure compliance.
A resident with severe disabilities was exposed to excessively high room temperatures due to a malfunctioning A/C unit, with temperatures reaching nearly 90°F. Multiple staff, including LPNs and CNAs, were aware of the issue for weeks, but no maintenance requests were documented and routine temperature monitoring was not performed. Facility leadership and maintenance staff were unaware of the ongoing problem, and the resident, who was unable to communicate discomfort, remained in the overheated room until the issue was discovered during a survey.
The facility failed to prevent neglect and medication errors, including not providing physician-ordered tube feeding and mobility assistance for a resident, leading to functional decline, and failing to administer medications as ordered for two residents. One resident missed multiple doses of IV antibiotics due to pharmacy and documentation issues, and another received the wrong IV medication due to staff error and lack of proper certification. Required assessments and investigations were not completed according to policy.
The facility did not keep nurse staffing postings current, as the displayed information was outdated for an extended period. The Staffing Coordinator, responsible for updating the postings, did not ensure they were updated, and the Nursing Home Administrator did not verify the postings as usual. There was no policy in place for posting nurse staffing data.
A resident with multiple complex medical conditions was given the wrong IV medication due to a medication error. Although the error was identified and reported, the facility did not conduct a thorough investigation or provide timely education to the involved LPNs on medication administration rights. The facility's documentation and staff interviews confirmed that required follow-up actions and staff training were not completed as per policy.
A resident with COPD and a physician's order for continuous oxygen was observed multiple times with an empty portable oxygen tank, resulting in a lack of oxygen delivery despite the nasal cannula being in place. Staff interviews revealed confusion over responsibilities for changing and initiating oxygen tanks, and the facility's policy limited initiation of oxygen therapy to licensed personnel. Full oxygen tanks were available in storage, but the resident did not receive the ordered therapy for an extended period.
Nurses and nurse aides failed to demonstrate appropriate competencies in medication administration, resulting in three residents not receiving medications as ordered. Errors included administering the wrong IV medication, missing multiple doses of an IV antibiotic due to supply and communication issues, and improper administration of eye drops and probiotics. Staff interviews revealed gaps in training, lack of policy adherence, and incomplete documentation.
Two residents did not receive their routine, physician-ordered medications upon admission due to the facility's failure to acquire and administer the medications in a timely manner. Despite the availability of some medications in the emergency drug kit, staff did not document attempts to access or administer them, and there was no clear communication with physicians regarding alternatives. Leadership confirmed the absence of policies guiding medication acquisition and use of the EDK, resulting in missed doses for newly admitted residents.
A medication pass observation revealed a 25% error rate when an LPN administered the wrong probiotic, failed to wait the recommended interval between two different eye drops, and gave both drops consecutively to a resident with diabetes and recent eye surgery. The MAR indicated the ordered probiotic was not given, and there was no facility policy for eye drop administration.
The facility's kitchen cooler was found in unsanitary condition, with peeling racks exposing rust and brownish-yellow stains. Various food items were stored improperly. The Dietary Director was aware of the issue but had not submitted a work order, and the Maintenance Director confirmed no work orders were received.
The facility did not have a qualified Infection Control Preventionist (ICP) with specialized training. The DON and an LPN were in training to become ICPs, but neither had completed the required training. Their training was assisted by a Regional Nurse Consultant who visits monthly. The previous ICP left in May, and the facility's policy mandates specialized training for the ICP role, which was not fulfilled.
The facility failed to maintain essential kitchen equipment safely, with a leaking reach-in cooler and steam table observed during a survey. Staff confirmed the issues and mentioned maintenance requests, but the Maintenance Director had not received any work orders. A review of work orders for May and June 2024 showed no records for the equipment, indicating a communication breakdown.
The facility failed to maintain accurate PASRR documentation for several residents, as their forms did not reflect current mental health diagnoses. This was confirmed through interviews and record reviews, revealing discrepancies between the PASRR forms and the residents' medical records and MDS assessments. The DON and SSD acknowledged their responsibility to ensure PASRR accuracy, but the process was not consistently followed.
The facility failed to complete MDS assessments on time for four residents, with delays attributed to other departments not completing their sections promptly. Two residents had their admission MDS assessments completed late, while two others had their Medicare 5-day MDS assessments delayed beyond the required timeframe.
A resident with unspecified hearing loss was inaccurately assessed in their MDS as having adequate hearing, despite requiring a dry erase board for communication. Facility staff, including the MDS Coordinator and DON, confirmed the error, acknowledging the resident's care plan for hearing difficulties. The facility's policy requires accurate assessments to meet residents' needs, which was not followed in this instance.
A resident's baseline care plan was not completed within the required timeframe after admission. Interviews with an LPN and the DON revealed confusion about the timeline for completing these plans, and the facility lacked a formal policy for baseline care plans.
The facility failed to update care plans for four residents, leading to deficiencies in care. One resident's care plan was not revised after transmission-based precautions were lifted. Another resident's laughing outbursts were not addressed in the care plan, despite a diagnosis of pseudobulbar affect. A third resident's care plan lacked interventions for skin-picking and wound care. Additionally, a resident receiving oxygen therapy had a care plan that did not include their oxygen, diabetes, or dysphagia needs.
The facility failed to provide proper oxygen therapy for four residents, with issues including lack of physician orders, improper documentation, and absence of signage indicating oxygen use. Residents were observed using oxygen at incorrect levels, and staff interviews revealed inconsistencies in monitoring and adjusting oxygen therapy according to physician orders.
A facility failed to limit PRN psychotropic medications to 14 days for a resident with mood disorder and dementia, and did not complete behavior and side effect monitoring for four residents as per physician orders. The MAR showed check marks instead of required documentation, indicating a lack of proper monitoring and documentation.
Failure to Maintain Safe Room Temperatures Due to Unrepaired A/C Unit
Penalty
Summary
A deficiency was identified when the facility failed to maintain safe and comfortable temperatures in a resident's bedroom due to an unrepaired rooftop air-conditioning (A/C) unit. Observations revealed that the resident's room had temperatures between 89.8 and 90.0 degrees Fahrenheit, with noticeable humidity and lack of cool airflow. The resident, who was nonverbal and dependent on staff for care, was found in a visibly uncomfortable state, with staff noting the room had been warm for about a month. Multiple staff members, including CNAs and LPNs, confirmed awareness of the persistent high temperatures in the room, and it was noted that the issue had not been formally reported or addressed in the facility's electronic communication log. The resident involved had significant medical conditions, including severe intellectual disabilities, acute and chronic respiratory failure, contractures, cognitive communication deficits, and generalized muscle weakness, necessitating assistance with personal care. The resident was unable to communicate preferences or discomfort regarding room temperature. Despite the resident's vulnerability, the maintenance staff had not routinely checked or documented room temperatures, and the Maintenance Director only measured the temperature after being prompted during the survey. The Maintenance Assistant and Director both expressed expectations for room temperatures to be significantly lower than what was observed, and acknowledged that the conditions were unsuitable for a resident. Interviews with facility leadership, including the DON and NHA, revealed a lack of awareness and formal process for monitoring and documenting room temperatures. The NHA stated that temperature checks were only performed in response to A/C outages and that staff were expected to report issues through an electronic system, though no such reports were found. The facility did not provide policies or procedures for temperature monitoring or staff communication regarding maintenance concerns. The deficiency was cited due to the failure to ensure the physical environment was maintained in a manner that assured resident safety and well-being, as required by regulation.
Plan Of Correction
Resident #5 was immediately moved to another room on 06/23/2025 with no adverse effects noted. Room #202 was closed on 06/23/2025. On 06/23/2025, a portable air conditioner was placed in room 202. An outside HVAC contractor detected a refrigerant leak on 06/26/2025; a recommendation for roof top unit (RTU) #3 replacement was received. A replacement unit was ordered on 06/26/2025. On 08/30/2025, an outside HVAC contractor added refrigerant to RTU #3. The new unit was installed on 07/11/2025 by an outside HVAC contractor. On 06/25/2025, the Maintenance Director tested room and hallway temperatures with no concerns identified. On 06/26/2025, an outside HVAC contractor completed a system check for the remaining RTUs to determine functionality. The recommendation was for the replacement of RTU #5, which was received. The replacement unit was ordered on 06/26/2025. No other recommendations were received for the remaining units. The NHA re-educated the Maintenance Director on 06/25/2025 on comfortable and safe temperature levels. Facility staff were re-educated on comfortable and safe temperature levels and submitting electronic work orders by 07/14/2025. Any staff not receiving education by 07/14/2025 will receive education prior to their next scheduled shift. The Maintenance Director/designee will complete random audits of temperatures in hallways and resident rooms 5 times a week for 4 weeks, 3 times a week for 4 weeks, and 1 time a week for one month. Any concerns will be addressed at the time of audit. Audit results, along with any concerns related to compliance, will be presented to the QA Committee (Administrator, Director of Nursing, Medical Director, MDS Coordinator, Social Services Director, Admissions Director, Maintenance Supervisor, Dietary Director) monthly at the Quality Assurance Performance Improvement meeting for review and any needed recommendations for 3 months. If non-compliance is identified, audits will start back at the beginning of the cycle occurring 4 weeks, 3 times a week for 4 weeks, and 1 time a week for one month.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
A deficiency occurred when the facility failed to maintain safe and comfortable temperatures in a resident's bedroom, as required by federal regulations. The air conditioning (A/C) system serving the resident's room was not functioning properly, resulting in room temperatures measured between 89.8 and 90.0 degrees Fahrenheit. Observations confirmed excessive warmth and palpable humidity in the room, with no noticeable cool air flow from the ceiling vent. The resident, who was nonverbal and dependent on staff for care, was found in a visibly uncomfortable state, with staff noting that the room had been warm for about a month. Multiple staff members, including LPNs, CNAs, and housekeeping, were aware of the elevated temperatures in the room and reported that the issue had persisted for several weeks. Despite this, there was no evidence that maintenance staff or facility leadership had taken timely action to monitor or address the temperature problem. The maintenance director and assistant were unaware of any recent complaints or issues with the A/C unit, and temperature checks in resident rooms were not routinely performed unless the A/C system was known to be out of order. Staff reported that maintenance requests were to be submitted electronically, but no such requests regarding the temperature issue were found in the facility's communication log. The resident affected by the deficiency had significant medical needs, including severe intellectual disabilities, respiratory failure, contractures, and muscle weakness, and was unable to communicate preferences or discomfort. The facility did not have a documented policy or procedure for routine temperature monitoring or for staff to communicate environmental concerns to maintenance. Facility leadership, including the DON and NHA, were not aware of the temperature issue in the resident's room and had not noticed elevated temperatures in the affected area. The lack of routine monitoring and communication resulted in the resident being exposed to unsafe and uncomfortable temperatures for an extended period.
Plan Of Correction
Resident #5 was immediately moved to another room on 06/23/2025 with no adverse effects noted. Room #202 was closed on 06/23/2025. On 06/23/2025, a portable air conditioner was placed in room 202. An outside HVAC contractor detected a refrigerant leak on 06/26/2025; a recommendation for roof top unit (RTU) #3 replacement was received. A replacement unit was ordered on 06/26/2025. On 06/30/2025, the outside HVAC contractor added refrigerant to RTU #3. The new unit was installed on 07/11/2025 by an outside HVAC contractor. On 06/25/2025, the Maintenance Director tested room and hallway temperatures with no concerns identified. On 06/26/2025, an outside HVAC contractor completed a system check for the remaining RTUs to determine functionality. The recommendation was for the replacement of RTU #5, which was received. The replacement unit was ordered on 06/26/2025. No other recommendations were received for the remaining units. The NHA re-educated the Maintenance Director on 06/25/2025 on comfortable and safe temperature levels. Facility staff were re-educated on comfortable and safe temperature levels and submitting electronic work orders by 07/14/2025. Any staff not receiving education by 07/14/2025 will receive education prior to their next scheduled shift. The Maintenance Director/designee will complete random audits of temperatures in hallways and resident rooms 5 times a week for 4 weeks, 3 times a week for 4 weeks, and 1 time a week for one month. Any concerns will be addressed at the time of audit. Audit results along with any concerns related to compliance will be presented to the QA Committee (Administrator, Director of Nursing, Medical Director, MDS Coordinator, Social Services Director, Admissions Director, Maintenance Supervisor, Dietary Director) monthly at the Quality Assurance Performance Improvement meeting for review and any needed recommendations for 3 months. If non-compliance is identified, audits will start back at the beginning of the cycle occurring 4 weeks, 3 times a week for 4 weeks, and 1 time a week for one month.
Failure to Prevent Neglect and Medication Errors
Penalty
Summary
The facility failed to protect residents from neglect by not providing physician-ordered tube feeding and failing to assist a resident in getting out of bed for 13 days, resulting in a decline in the resident's functionality. The resident, who was admitted with multiple serious diagnoses including sepsis, acute respiratory failure, and protein-calorie malnutrition, was supposed to receive enteral nutrition via a tube feed and assistance with mobility. Observations and interviews revealed that the tube feeding was inconsistently administered due to issues with the pump and lack of staff knowledge, and the resident was not assisted out of bed because staff were waiting on therapy and a wheelchair was missing. Documentation showed missed and undocumented feedings, and the resident experienced weight loss and a decline in physical function during this period. Additionally, the facility failed to administer medications in accordance with physician orders for two residents. One resident did not receive all prescribed doses of an IV antibiotic due to pharmacy supply issues and lack of proper tracking, resulting in missed doses and the premature removal of a PICC line before the antibiotic course was completed. Staff interviews confirmed confusion and lack of communication regarding the medication schedule, and documentation did not support that the full course was administered as ordered. Another resident received the wrong IV medication due to a medication administration error involving two LPNs, one of whom was not IV certified. The error was not fully investigated, and required neurological assessments were not completed as ordered. Facility policies on medication administration and abuse prevention were not followed, and staff involved did not receive appropriate education or oversight regarding medication rights and administration procedures.
Failure to Maintain Up-to-Date Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that the posted nurse staffing data was up-to-date and current for the period from 4/18/25 to 4/30/25. Observations on 4/29/25 revealed that the Daily Nurse Staffing sheet displayed in the front lobby was dated 4/17/25 and had not been updated through at least 4/29/25. Interviews with the Staffing Coordinator confirmed she was responsible for posting the data but had not ensured it was done, citing changes in her work schedule and not realizing the postings were outdated. The Nursing Home Administrator also acknowledged that she typically checked the postings but had not done so during this period. It was further confirmed that the facility did not have a policy regarding the posting of Daily Nurse Staffing data. Photographic evidence was obtained to support these findings.
Failure to Investigate and Educate Staff After Medication Error
Penalty
Summary
The facility failed to thoroughly investigate and provide staff education following a medication error involving a resident who was admitted with multiple complex diagnoses, including intraspinal abscess, sepsis, and chronic myeloproliferative disease. The resident was inadvertently administered the wrong intravenous medication, Cefepime HCl, instead of the ordered Daptomycin. Documentation shows that the error was identified, the physician and family were notified, and neuro checks were initiated, but there was no evidence of adverse reactions at the time. However, the facility's progress notes lacked a follow-up entry for the day after the incident. Interviews revealed that the investigation into the medication error was incomplete. The DON, who was new to the position, provided only one investigation statement from the LPN involved and acknowledged that the form was not filled out correctly. The DON also stated that there was no proof that staff education on the seven rights of medication administration had been provided at the time of the incident. Other staff members confirmed that they had not received formal education related to medication rights or incident response until much later. The facility's policy requires immediate and thorough investigation of alleged neglect, including obtaining statements from all involved staff and providing education to prevent recurrence. In this case, the investigation did not include statements from all relevant staff, and there was no documentation of timely staff education. The lack of a comprehensive investigation and staff training following the medication error constituted a failure to respond appropriately to an alleged violation, as required by facility policy.
Failure to Provide Continuous Oxygen Therapy as Ordered
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD) and a physician's order for continuous oxygen at 2 liters via nasal cannula was observed multiple times throughout the day with an empty portable oxygen tank. The resident, who required oxygen due to asthma and reported episodes of wheezing, was seen in her wheelchair both in her room and on the patio with the nasal cannula in place but no oxygen being delivered, as the tank was empty. This was confirmed by several staff members, including CNAs and a registered nurse, who acknowledged that the oxygen tank had been empty since the morning and had not been replaced as required by the resident's care plan and physician's orders. Interviews with staff revealed confusion regarding responsibilities for changing and initiating portable oxygen tanks, with CNAs stating they typically changed the tanks and nurses indicating that only licensed staff should initiate oxygen therapy. The facility's policy specified that only physicians, RNs, LPNs, and respiratory therapists are authorized to initiate oxygen therapy. Despite the availability of full oxygen tanks in storage, the resident did not receive the ordered continuous oxygen therapy for an extended period, as evidenced by direct observation and staff interviews.
Medication Administration Competency Deficiencies
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the appropriate competencies and skills to administer medications as ordered for three residents. In one case, a resident with complex medical conditions, including sepsis and osteomyelitis, was given the wrong intravenous medication due to a lack of verification and proper handoff between two LPNs, one of whom was not IV certified. The medication error was not fully investigated, and required neurological assessments were not completed according to protocol, with documentation ceasing before the required monitoring period ended. Staff interviews revealed gaps in education regarding medication rights and incident response procedures. Another resident, admitted with sepsis and other serious diagnoses, did not receive all prescribed doses of an IV antibiotic due to medication unavailability and communication lapses. The MAR and progress notes showed that eight doses were missed, and documentation was inconsistent regarding physician notification and medication holds. Staff interviews confirmed difficulties in obtaining the medication and confusion about whether the full course was completed. The resident's PICC line was discontinued before the antibiotic regimen was finished, necessitating reinsertion for completion of therapy. A third resident experienced multiple medication administration errors during observation. An LPN administered a probiotic that was not the same as the one ordered, and two different eye drops were given consecutively without the recommended interval between administrations. The facility lacked a policy for eye drop administration, and staff were unclear about the equivalency of probiotics. These incidents demonstrate failures in medication verification, adherence to administration protocols, and staff competency in medication management.
Failure to Provide Admission Medications Due to Gaps in Acquisition and Documentation
Penalty
Summary
The facility failed to ensure that routine, physician-ordered medications were acquired and provided upon admission for two residents. For one resident with multiple diagnoses including a right femur fracture, chronic pain, asthma, fibromyalgia, and migraines, there was no documentation of medication reconciliation or communication with the physician at admission. Progress notes indicated that several ordered medications, including Lyrica, Eletriptan, Venlafaxine, and Senokot S, were not available or administered for up to three days after admission. The medication administration record confirmed these medications were not given, and staff documented that medications were pending pharmacy delivery or not available, with some offers of alternative pain relief being refused by the resident. Another resident, admitted with diagnoses such as spondylosis, type 2 diabetes with nephropathy, muscle spasm, bacteremia, and repeated falls, also did not receive ordered medications upon admission. The resident reported not receiving any medications, including those for diabetes, during the first night, which was corroborated by the medication administration record and progress notes. The facility's emergency drug kit (EDK) contained metformin and other relevant medications, but there was no documentation that these were accessed or administered. Staff interviews revealed inconsistent processes for obtaining and administering medications from the EDK and pharmacy, with some staff indicating that medications could be delayed depending on delivery schedules and lack of clear documentation or communication with physicians regarding alternatives. Further interviews with facility leadership, including the DON and NHA, confirmed gaps in the medication acquisition process, lack of documentation regarding medication availability, and absence of policies related to obtaining medications from pharmacy services or the EDK. The DON acknowledged that medications such as metformin and rosuvastatin were available in the EDK but could not confirm why they were not administered. The NHA stated there were no policies guiding the acquisition of medications or use of the EDK, contributing to the failure to provide necessary medications to residents upon admission.
Medication Administration Error Rate Exceeds 5% Due to Multiple Errors
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, as required. During an observation of medication administration for one resident, a total of twelve medication opportunities were reviewed, and three errors were identified, resulting in a 25% error rate. The errors included the administration of saccharomyces boulardii instead of the ordered lactobacillus probiotic, failure to wait the recommended interval between administering two different types of eye drops (latanoprost and timolol) in the same eye, and the administration of both eye drops consecutively without the required waiting period. The staff member involved confirmed the administration of the incorrect probiotic and did not follow the recommended procedure for eye drop administration. The resident involved had a history of diabetes mellitus and recent eye surgery, with orders for multiple oral medications, eye drops for glaucoma, and insulin. The medication administration record showed that the resident was to receive lactobacillus, but this was substituted with saccharomyces without a corresponding order at the time of administration. Additionally, the facility did not have a policy or procedure in place for the administration of eye drops, and staff were not following best practices for timing between different ophthalmic medications. These actions and omissions led to the identified medication errors.
Sanitation Deficiency in Kitchen Cooler
Penalty
Summary
The facility failed to maintain the reach-in cooler in a sanitary condition within the kitchen. During an inspection, the cooler was found to contain various food items, including a container of prepared food, an open carton of eggs, a container of turkey, half a head of lettuce, a cucumber, a package of meat, and a silver pan of corn, all covered with plastic wrap. The cooler's racks were observed to have peeling white coating, exposing rusted bars, and were stained with a brownish-yellow residue. The Dietary Director acknowledged the need to replace the racks and expressed a desire to replace the entire cooler. However, she was unaware of when a work order was submitted, despite the facility using an online system for such requests. The Maintenance Director confirmed that no work orders for the cooler had been received. A review of the facility's work order report for May and June 2024 showed no entries for the reach-in cooler.
Lack of Qualified Infection Control Preventionist
Penalty
Summary
The facility failed to ensure the presence of a qualified Infection Control Preventionist (ICP) with specialized training in infection control and prevention. During an interview, the Director of Nursing (DON) stated that both she and a Licensed Practical Nurse (LPN), referred to as Staff C, were in training to become the facility's ICPs. However, neither had completed the necessary specialized training. The DON mentioned that their training was being assisted by a Regional Nurse Consultant (RNC) who visits the facility once a month. The Nursing Home Administrator confirmed that the previous ICP left in May 2024, and currently, the DON and Staff C are undergoing training. The facility's policy requires that the ICP must have specialized training beyond initial professional education before assuming the role, which neither the DON nor Staff C had completed at the time of the survey.
Failure to Maintain Essential Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in a safe operating condition, as observed during a survey. The reach-in cooler was found with a wet towel underneath and water pooling on the floor, indicating a leak. Additionally, the steam table was observed with wet towels and buckets on the lower shelf to catch water dripping from the upper shelf where food storage compartments were located. Staff E, a dietary staff member, confirmed the leaks and mentioned that a maintenance request had been submitted, although the drain was missing on the steam table, necessitating the use of buckets. The Dietary Director acknowledged that the reach-in cooler had been temporarily fixed by on-site maintenance and that the steam table did not leak consistently. However, the Maintenance Director stated that he had not received any work orders for either the reach-in cooler or the steam table. He only became aware of the issues when informed by the kitchen staff during the survey. A review of the facility's work order report for May and June 2024 showed no records of work orders for the problematic equipment, indicating a communication breakdown in the maintenance request process.
Inaccurate PASRR Documentation for Residents
Penalty
Summary
The facility failed to ensure the accuracy of admission diagnoses on the Level I Preadmission Screening and Resident Review (PASRR) forms and did not update these forms upon the addition of new diagnoses for thirteen residents. This deficiency was identified through interviews and record reviews, revealing that the PASRR forms for these residents were not accurately reflecting their current mental health diagnoses. For instance, Resident #43's PASRR form did not include updated diagnoses of vascular dementia and adjustment disorder with mixed anxiety and depressed mood, despite these being documented in the resident's medical records and medication administration records. Similarly, Resident #40's PASRR form was outdated and did not reflect the resident's current diagnoses of unspecified dementia and major depressive disorder. The review of the medication administration records and Minimum Data Set (MDS) assessments for several residents, including Residents #6, #59, and #37, showed discrepancies between the documented diagnoses and those listed on the PASRR forms. These inconsistencies indicate a failure to update the PASRR forms as required when new diagnoses were made or when residents were readmitted to the facility. Interviews with the Director of Nursing (DON) and the Social Services Director (SSD) confirmed that it was their responsibility to ensure the accuracy of the PASRR forms upon admission and to update them when new diagnoses were added. However, the review of the clinical records showed that this process was not consistently followed, leading to multiple residents having inaccurate PASRR forms. This oversight in maintaining accurate PASRR documentation could potentially impact the care and services provided to residents with mental disorders or intellectual disabilities.
Delayed Completion of MDS Assessments
Penalty
Summary
The facility failed to ensure the timely completion of the Minimum Data Set (MDS) assessments for four residents, which is a requirement for comprehensive resident assessment. Resident #47's admission MDS assessment was completed late, with an Assessment Reference Date (ARD) of 5/28/2024, but not completed until 6/5/2024. Similarly, Resident #273's admission MDS assessment was delayed, with an ARD of 6/12/2024, but not completed until 6/20/2024. These delays were acknowledged by Staff B, the Registered Nurse and MDS Coordinator, who attributed the lateness to other departments not completing their sections of the assessment on time. Additionally, the facility did not complete the Medicare 5-day MDS assessments for Resident #57 and Resident #17 within the required timeframe. Resident #57 was discharged on 2/3/2024, but the assessment was not completed until 3/20/2024. Similarly, Resident #17 was discharged on 1/4/2024, with the assessment also completed on 3/20/2024. Staff B was unable to provide reasons for these delays as she was not employed at the facility during that period. According to the Centers for Medicare & Medicaid Services guidelines, these assessments should have been completed within 14 days of the ARD.
Inaccurate MDS Assessment for Hearing Impaired Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident with a diagnosis of unspecified hearing loss. The resident was observed in a wheelchair watching television and communicated using a dry erase board, indicating a significant hearing impairment. Despite this, the resident's Quarterly MDS assessment inaccurately documented that the resident had adequate hearing with no difficulty in normal conversation, social interaction, or listening to TV. This discrepancy was identified during a review of the resident's care plan, which had interventions in place for hearing difficulties, such as using a dry erase board for communication. Interviews with the facility staff, including the MDS Coordinator and the Director of Nursing (DON), confirmed the inaccuracy in the MDS assessment. The MDS Coordinator acknowledged the error, noting that the resident was care planned for difficulty hearing, and the DON confirmed that the resident was unable to hear and required the use of a dry erase board for communication. The facility's policy on comprehensive care plans emphasizes the need for accurate assessments to meet residents' needs, which was not adhered to in this case.
Failure to Timely Complete Baseline Care Plan
Penalty
Summary
The facility failed to complete a baseline care plan in a timely manner for a resident, identified as #274, who was admitted on an unspecified date. The baseline care plan for this resident was not completed until 6/17/2024, which was beyond the expected timeframe. Interviews with staff revealed a lack of clarity regarding the timeline for completing baseline care plans. A Licensed Practical Nurse (LPN) indicated that unit managers typically initiate these plans, but could not specify when they should be completed. The Director of Nursing (DON) stated that baseline care plans should be completed by the admitting nurse within 48 hours of admission. However, the facility did not have a formal policy in place for baseline care plans, as confirmed by the DON.
Failure to Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to revise the comprehensive care plans for four residents, leading to deficiencies in their care. For one resident with a history of ESBL in urine, the care plan was not updated to reflect the discontinuation of transmission-based precautions, despite the precautions being lifted weeks prior. The oversight was confirmed by the RN/MDS Coordinator, who acknowledged the care plan should have been updated when the precautions were no longer necessary. Another resident, diagnosed with Alzheimer's disease and other mental health conditions, exhibited sporadic outbursts of laughter, which were not addressed in the care plan. Despite a diagnosis of pseudobulbar affect and a recommendation for Nuedexta, there were no orders for the medication, and the care plan lacked any focus, goal, or intervention related to the laughing outbursts. Staff interviews revealed a lack of communication regarding the new diagnosis and the absence of documentation in the care plan. A third resident with a history of skin-picking disorder and venous ulcers had a care plan that did not address the behavior of removing dressings from wounds. The resident's care plan was also missing goals and interventions for the venous ulcers and did not include care for a toe wound. Staff interviews indicated a lack of awareness and communication about the resident's behavior and wound care needs. Additionally, another resident receiving oxygen therapy and diagnosed with diabetes and dysphagia had a care plan that did not include these conditions, highlighting a failure to update the care plan to reflect the resident's current needs.
Oxygen Therapy Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide oxygen therapy in accordance with professional standards for four residents. Resident #47 was observed using oxygen without proper documentation in the medication administration record, and there was no signage indicating oxygen use outside the resident's room. Despite having a physician's order for PRN oxygen, the administration was not recorded, indicating a lack of adherence to the prescribed treatment plan. Resident #274, who has chronic obstructive pulmonary disease and is dependent on supplemental oxygen, was observed using oxygen without a physician's order in place. The staff, including an LPN and the Director of Nursing, confirmed the absence of an order and acknowledged the lack of signage indicating oxygen use. This oversight highlights a failure in ensuring that physician orders are documented and followed, as well as a lack of communication regarding oxygen therapy protocols. Resident #14 was receiving oxygen therapy at a higher rate than prescribed, with no documentation of the administration in the medication record and no signage indicating oxygen use. Similarly, Resident #29 was observed using oxygen at a lower rate than ordered, with the resident unaware of the prescribed oxygen level. Interviews with staff revealed inconsistencies in monitoring and adjusting oxygen levels according to physician orders, further demonstrating a systemic issue in managing oxygen therapy for residents.
Failure to Limit PRN Psychotropic Medications and Monitor Side Effects
Penalty
Summary
The facility failed to ensure that physician-ordered psychotropic medications used on an as-needed basis were limited to 14 days for one resident. This resident was admitted with diagnoses of mood disorder and dementia and had an order for Lorazepam without an end date. The Director of Nursing acknowledged that psychotropic medications should be limited to 14 days and reviewed by the physician if continued use is necessary. The facility's policy requires that PRN orders for psychotropic drugs be limited to 14 days unless the physician documents a rationale for extension. Additionally, the facility did not complete behavior and side effect monitoring of psychotropic medication use in accordance with physician orders for four residents. For one resident, the Medication Administration Record (MAR) showed check marks instead of the required 'Yes' or 'No' documentation for monitoring behaviors and side effects. This resident had a history of Alzheimer's disease, mood disorder, and other psychiatric conditions, and was observed having sporadic outbursts of laughter. Staff interviews revealed a lack of documentation and communication regarding the resident's behavior and medication administration. For another resident, the MAR also showed check marks instead of the required documentation for monitoring behaviors and side effects. This resident had a diagnosis of depression and was observed sleeping frequently. The care plan indicated a risk for adverse reactions to psychotropic medications, but the required monitoring was not documented. Similar issues were found with two other residents, where the MAR showed check marks instead of the required documentation, indicating a failure to monitor and document behaviors and side effects as per physician orders and facility policy.
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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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