Lexington Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Petersburg, Florida.
- Location
- 6300 46th Ave N, Saint Petersburg, Florida 33709
- CMS Provider Number
- 105072
- Inspections on file
- 33
- Latest survey
- July 17, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Lexington Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to prevent accidents and provide adequate supervision for a resident with severe cognitive impairment who sustained a fall with injury, and did not ensure a safe environment for two residents who smoked and required wheelchairs, requiring them to navigate unassisted through hazardous areas without staff supervision or proper smoking receptacles.
Surveyors identified multiple sanitation and maintenance issues in the kitchen, including dirty equipment, rusted surfaces, stained ceiling filters, water leaks, insect presence during food prep, and trash accumulation both inside and outside the kitchen. The Certified Dietary Manager was aware of several issues but cited challenges with cleaning procedures and shared responsibilities for maintaining cleanliness.
Several dependent residents did not receive consistent assistance with ADLs, including grooming, nail care, shaving, toileting, and showers, as required by their care plans. Residents reported long waits for help, missed care, and unmet hygiene needs, while staff interviews and documentation confirmed lapses in providing and recording necessary support.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs. These deficiencies were observed during the survey and directly affected residents requiring assistance with bowel and bladder management.
Multiple staff were observed failing to follow infection prevention protocols, including improper incontinence and catheter care without glove changes or hand hygiene, lack of PPE use in a contact isolation room, and non-compliance with policies on artificial fingernails and hair containment. Documentation of staff competency and infection control training was incomplete, and staff interviews revealed gaps in education and monitoring.
A resident with a gastrostomy tube was observed independently administering enteral nutrition without an assessment, physician order, or care plan focus authorizing self-administration. Despite having intact cognition and relevant diagnoses, the facility did not follow its policy requiring interdisciplinary assessment and documentation for self-administration of medications.
A resident with dementia and significant confusion suffered an unwitnessed fall resulting in a skull fracture. Despite care plan interventions, the DON did not report the incident as an injury of unknown source, citing no care plan violation, even though staff and the PMHNP indicated the resident was unable to request assistance. Facility policy required reporting such incidents, but this was not done.
A resident with intact cognition was transferred to the hospital for evaluation and treatment without receiving written notification about bed-hold options or appeal rights prior to the transfer. The required transfer and discharge notice form was incomplete and dated after the resident's return, and staff interviews confirmed that the necessary documentation and notifications were not provided at the time of transfer.
A resident with a new diagnosis of major depressive disorder did not have a properly completed or submitted Level II PASRR evaluation request following a significant change in condition. Facility staff failed to provide evidence of notification to the state authority, and documentation was incomplete and unsigned, contrary to policy requirements.
A deficiency was cited when a resident's care plan did not include all necessary components, such as measurable timetables and specific actions, resulting in incomplete planning and documentation of the resident's needs.
A resident with a recent history of falls did not have timely, written, signed, and dated physician progress notes following each required visit. Staff and DON confirmed that physician documentation was missing from the medical record for several months, contrary to facility policy, with the missing notes later found in the medical records department.
A resident with ESRD on dialysis did not receive multiple prescribed medications as ordered, with missed doses documented as refusals. The resident reported not refusing medications but missing them due to being at dialysis. Staff interviews confirmed that physician notification and documentation were required for missed doses, but these steps were not completed.
Surveyors found that the medication error rate in the facility was 5 percent or greater, indicating that medication administration was not consistently accurate and exceeded regulatory standards.
The facility did not consistently provide food that accommodated resident allergies, intolerances, and preferences, and failed to offer appealing meal options, as observed during the survey.
The facility did not provide documentation of required quarterly visual inspections and semi-annual testing for fire service backflow tamper switches, which were found installed but not included in inspection or testing reports. The Facility Manager confirmed these devices had not been inspected or tested as required by NFPA standards.
Surveyors identified that the facility did not properly maintain its automatic fire sprinkler system, with multiple corroded and dust-loaded sprinkler heads found in areas such as the front porch, laundry washroom, and behind the dryers. These deficiencies were confirmed by the Facility Manager during the inspection.
An employee was observed smoking outside of a designated area on facility property where required noncombustible ashtrays and self-closing metal disposal containers were not provided, despite the facility's no-smoking policy. The deficiency was confirmed by the Facility Manager during the survey.
A corridor door with a self-closing mechanism leading to the clean utility room by the nurse's station failed to close or self-latch when tested, as confirmed by the Facility Manager. This failure to maintain the fire door in accordance with NFPA 101 and NFPA 80 standards resulted in a deficiency.
The facility failed to implement an effective infection prevention and control program, resulting in ongoing skin rashes among residents and staff. Multiple residents reported itching and lack of effective treatment or cleaning measures. Staff also experienced similar symptoms, and the facility's infection preventionist did not track the outbreak effectively. The DON and NHA were unaware of the full scope of the issue, leading to continued spread.
The facility failed to provide timely care plan meeting notifications, hindering resident and representative participation in care planning. A resident with severe cognitive impairment had insufficient attempts to contact their POA, while another resident with intact cognition received inadequate notification. Additionally, a resident with moderate cognitive impairment lacked documentation for care plan invitations and summaries. The MDS Coordinator acknowledged issues with documentation and notification processes.
Failure to Prevent Accidents and Ensure Safe Smoking Environment
Penalty
Summary
The facility failed to implement appropriate interventions and provide adequate supervision to prevent accidents and injuries for multiple residents. One resident with severe cognitive impairment, a history of falls, and a recent diagnosis of dementia and agitation was found on the floor with a skull fracture after attempting to get out of bed unassisted. The resident's care plan included reminders to request assistance and keeping the call light within reach, but interviews with staff and the psychiatric nurse practitioner revealed that the resident was unable to use the call light due to confusion and severe cognitive deficits. Despite these known limitations, no additional supervision or interventions were implemented prior to the fall, and the psychiatric nurse practitioner was not notified of the incident, which would have required a follow-up assessment. Additionally, the facility failed to ensure a safe environment for residents who smoke. Two residents who required the use of a wheelchair and had mobility impairments were required to sign out on a leave of absence and navigate unassisted through the parking lot, over speed bumps, and across potholes to reach an off-premises smoking area. Observations confirmed that no staff supervision or smoking receptacles were present in the area where these residents smoked. One resident was observed struggling to move her wheelchair over a speed bump, and both residents expressed concerns about the difficulty and safety of accessing the designated smoking area. Review of the facility's policies and staff interviews indicated that smoking assessments were completed without direct observation of residents smoking, and staff were unclear about the requirements for supervision and safe smoking practices. The facility's policy stated that resident supervision should be based on individual assessments and physician orders, but in practice, residents with mobility and cognitive impairments were left unsupervised in potentially hazardous environments, leading to avoidable risks and incidents.
Sanitation and Maintenance Deficiencies in Kitchen and Food Service Areas
Penalty
Summary
Surveyors observed multiple sanitation and maintenance deficiencies in the facility's main kitchen during an inspection. The juice machine filter was found with visible dirt and debris, and the Certified Dietary Manager (CDM) was unaware of how to clean it, stating that new filters would need to be ordered and installed by the vendor. The juice machine itself had brown stains and rust on its stainless-steel surfaces, which the CDM indicated could not be cleaned. Ceiling filters above food preparation and service areas were stained and covered in dust and dirt, and a light fixture near the food prep area had brown stains and bio-growth. Water was observed leaking near this light fixture, and the CDM confirmed that maintenance was aware of the issue. Kitchen mixer utensils stored above clean dishes were found with dust and sticky substances, and the CDM stated these were no longer in use and should have been removed. In the freezer, ice buildup was present on surfaces and on top of food boxes, which the CDM acknowledged and said maintenance would address. Additionally, an insect was observed flying over chicken being prepared for lunch, which the CDM attributed to staff leaving the back door open, allowing insects to enter the kitchen. The chicken was immediately discarded. Outside the kitchen, trash and standing water were found near the kitchen door, with the CDM noting that the water was leaking from an air conditioning unit and had been an ongoing problem, leading to mosquito breeding. The area around the dumpster was littered with trash, including used gloves, papers, and incontinence pads. The CDM stated that cleaning responsibilities were shared between nursing and maintenance, but enforcement was difficult. Facility policy requires all food preparation and service areas to be maintained in a clean and sanitary condition, but these observations indicated noncompliance.
Failure to Provide Consistent Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for several dependent residents, as evidenced by direct observations, resident interviews, and record reviews. Multiple residents were found with untrimmed fingernails, facial hair, and reported not receiving help with grooming tasks such as nail trimming and shaving, despite care plans indicating the need for staff assistance. Residents expressed that staff either promised help that was not delivered or stated that staff were too busy to assist. Care plans for these residents documented self-care deficits and required staff interventions, including hands-on assistance and cueing, which were not consistently implemented. In addition to grooming deficiencies, residents reported and records confirmed delays and inconsistencies in receiving toileting care and showers. Some residents described waiting over an hour for staff to respond to call lights for toileting assistance, resulting in prolonged periods of incontinence. Documentation in the CNA Kardex revealed multiple dates where toileting care was not recorded, and residents reported not receiving showers as scheduled or preferred. Staff interviews confirmed that residents should be changed every two hours and that documentation should occur at the time of care, but this was not consistently practiced. The affected residents had significant medical histories, including dementia, hemiplegia, Parkinson’s disease, encephalopathy, spinal cord injury, morbid obesity, and chronic illnesses, all contributing to their dependence on staff for ADLs. Despite individualized care plans outlining the need for substantial or maximal assistance with hygiene, grooming, and toileting, the facility did not ensure these services were provided as required. Facility policy also mandated support for ADLs to maintain residents’ hygiene and dignity, but observations and interviews demonstrated that these standards were not met for multiple residents.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the care provided to residents requiring assistance with bowel and bladder management.
Infection Control Lapses in Staff Practices and Policy Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in staff practices and policy implementation. Certified Nursing Assistants (CNAs) were observed providing incontinence and catheter care without adhering to proper infection control protocols. One CNA used the same cleansing wipe to clean both the peri area and catheter tubing of a resident with a urinary catheter, without changing gloves or performing hand hygiene, even after contact with stool. Another CNA provided catheter care using a single washcloth for both the penis and catheter tubing, again without changing gloves or performing hand hygiene. Review of competency checklists revealed incomplete documentation and a lack of observed return demonstrations for these staff members, with one CNA stating she had not received additional training at the current location and the Infection Preventionist confirming that visual skills check-offs were not routinely performed or documented. Additional deficiencies were observed regarding staff adherence to facility policies on personal appearance and use of personal protective equipment (PPE). One LPN was observed with artificial fingernails extending past the fingertips, in violation of CDC recommendations and facility expectations, though the employee handbook did not explicitly prohibit artificial nails. Another staff member was observed with long, untethered braids that came into contact with a resident and bed linens during care, despite the expectation for staff to be neat and well-groomed. The facility's policy on employee appearance was found to be vague and did not specifically address artificial nails or hair containment. Further, staff failed to implement contact isolation precautions as required. Two CNAs entered a contact isolation room without donning PPE or gloves and did not perform hand hygiene before entering. One CNA stated he was unaware of the resident's contact precautions, while the other admitted to not paying attention to the signage. Interviews with the Infection Preventionist and DON revealed that while infection control is discussed during orientation, there is no structured or documented observation of staff practices, and compliance rates are not tracked. These failures collectively demonstrate a lack of consistent implementation and monitoring of infection prevention and control measures.
Failure to Assess and Authorize Self-Administration of Enteral Nutrition
Penalty
Summary
The facility failed to ensure that an assessment for self-administration of enteral nutrition was completed for a resident who was observed independently administering his enteral nutrition via gastrostomy tube. During observation, the resident was seen self-administering his enteral nutrition with the head of his bed flat. The resident confirmed that although nurses typically provide his enteral nutrition during scheduled meal times, he also self-administers it. Review of the resident's medical record revealed diagnoses including malignant neoplasm of the thyroid gland, severe protein calorie malnutrition, gastroesophageal reflux disease, and gastrostomy status. The resident had a BIMS score indicating intact cognition and had active physician orders for enteral feeding, but there was no documentation of an assessment for self-administration of enteral nutrition. Further review showed there was no physician order authorizing the resident to self-administer his enteral nutrition, nor was there any indication in the care plan that self-administration was permitted or planned. Facility policy requires an interdisciplinary team assessment and physician order before a resident may self-administer medications, including enteral nutrition, and mandates that the care plan reflect this arrangement. Staff confirmed that no such assessment, order, or care plan focus was present for this resident.
Failure to Report Serious Injury of Unknown Source and Neglect
Penalty
Summary
The facility failed to report an allegation of serious injury of unknown source and neglect for a resident who experienced an unwitnessed fall resulting in a skull fracture. The resident, who had a history of cognitive impairment, dementia, and confusion, was found on the floor with facial injuries and was subsequently diagnosed with a skull fracture and scalp contusion at the hospital. Her care plan included interventions such as the use of a mechanical lift with two staff for transfers and keeping the call light within reach, but she attempted to get out of bed without assistance. Interviews revealed that the DON did not consider the incident an adverse event or injury of unknown source, stating there was no violation of the care plan since the resident did not call for help. The DON also indicated that the event did not need to be reported to the State Agency. However, the resident's PMHNP and an LPN both described the resident as very confused and unable to use the call light or request assistance, contradicting the DON's assessment of the resident's capabilities. The PMHNP was not informed of the fall, and the LPN stated the resident would not have known how to use the call light. A review of facility policy showed that all reports of abuse, neglect, or injuries of unknown origin are to be reported to local, state, and federal agencies as required by regulations. The policy also requires immediate reporting of suspected abuse, neglect, or injury of unknown source to the administrator and other officials according to state law. Despite these requirements, the facility did not report the incident as required.
Failure to Provide Timely Written Notification of Hospital Transfer and Bed-Hold Policy
Penalty
Summary
The facility failed to provide written notification to a resident and the resident's representative prior to a hospital transfer. A resident with intact cognition, as indicated by a BIMS score of 15, reported not receiving any information about bed-hold options before being transferred to the hospital for evaluation and treatment of shortness of breath and chest pain. The resident expressed concern about returning to the facility in time to retain her bed, indicating a lack of communication regarding her rights and options during the transfer process. Record review showed that the Nursing Home Transfer and Discharge Notice form for the resident was incomplete, missing both the physician/designee and resident/representative signatures, and was dated after the resident's return from the hospital. Interviews with staff confirmed that the required notification and documentation were not provided at the time of transfer, and the facility's policy requires such notifications to be completed on the same day as the transfer. The deficiency was identified through review of records and staff interviews.
Failure to Notify State Authority After Significant Change in Mental Health Condition
Penalty
Summary
The facility failed to notify the appropriate state mental health or intellectual disability authority after a significant change in the mental condition of a resident with a new diagnosis of major depressive disorder. The resident was originally admitted with no indication of serious mental illness or intellectual disability, as documented in the initial PASRR screening. However, after a new diagnosis of major depressive disorder was made, there was no evidence that a Level II PASRR evaluation request was properly completed, signed, or submitted to the state agency. The documentation provided lacked signatures, patient identification, and proof of transmission, and no Level II evaluation or determination was available by the end of the survey. Interviews with facility staff, including the DON and ADON, revealed that the process for identifying and referring residents with new mental health diagnoses relies on provider communication and internal notification. Despite this, the required referral and documentation for the resident's significant change in condition were not completed according to policy and regulatory requirements. The facility's policy mandates that residents with new or suspected mental disorders or intellectual disabilities be referred for a Level II PASRR evaluation, but this process was not followed in this case.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was based on observations and review of the care planning process, which did not ensure that all aspects of the resident's needs were assessed and addressed in a comprehensive and measurable manner.
Failure to Maintain Timely Physician Progress Notes
Penalty
Summary
A deficiency was identified when the attending physician failed to provide written, signed, and dated progress notes following each required visit for one resident. The resident, who had a recent history of falls and required stitches, did not have timely physician progress notes documented in the electronic medical record. Review of the resident's records revealed gaps in physician documentation, with the most recent notes either missing or not uploaded for several months. Staff interviews confirmed that only psychiatric and ARNP notes were present, and the Director of Nursing acknowledged the absence of physician notes for an extended period, stating that this was not optimal. Further review of facility policy indicated that physician progress notes are required to be maintained for each resident and must reflect each visit, including the physician's signature and date. The deficiency was further substantiated when the DON confirmed that summaries in the record did not constitute physician notes and that the lack of documentation for several months was unacceptable. The missing notes were later found in the medical records department, which had a staffing vacancy, but this did not mitigate the initial failure to maintain timely and complete physician documentation as required by facility policy.
Failure to Administer Medications as Ordered and Notify Physician of Missed Doses
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders and did not document physician notification for missed medications for a resident with end stage renal disease (ESRD) who was dependent on renal dialysis. Review of the resident's Medication Administration Record (MAR) for June and July 2025 revealed multiple missed doses, including 31 missed doses of Lactobacillus, five missed doses of house protein, and single missed doses of atorvastatin calcium, ferrous sulfate, and a multivitamin. The MAR indicated these medications were marked as refused, but the resident stated she sometimes did not receive her medications because she was at dialysis and denied refusing them. Interviews with nursing staff and the Director of Nursing confirmed that a refusal should be documented, the physician should be notified, and a progress note should be entered. However, there was no documentation of physician notification for the missed medications. Facility policy requires medications to be administered as prescribed, refusals to be followed by physician notification, and medication errors to be documented and reviewed. These procedures were not followed in this case, resulting in the deficiency.
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. 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.
Failure to Accommodate Resident Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not consistently provide appealing food options. This deficiency was identified through observations and review of food service practices, which revealed that residents were not always provided with meals that met their individual dietary needs and preferences.
Failure to Inspect and Test Fire Service Backflow Tamper Switches
Penalty
Summary
The facility failed to maintain the automatic fire alarm system (AFAS) in accordance with NFPA 101 and NFPA 72 requirements. During a record review with the Facility Manager, it was discovered that there was no documentation of the required quarterly visual inspections and semi-annual testing of the fire service backflow tamper switches. These devices were not listed on any inspection or testing reports, indicating that they had not been included in the facility's regular fire alarm system maintenance program. During a facility tour, the tamper switches were observed to be installed on the fire service backflow device. In an interview, the Facility Manager acknowledged that they were unaware the devices were not being inspected or tested. The deficiency was identified through both documentation review and direct observation, confirming that the required maintenance and testing procedures for these components of the fire alarm system were not being followed.
Plan Of Correction
The facility Administrator/Designee contacted vendor to service the backflow tamper switches. The fire service backflow tamper switches were inspected and tested by a vendor company. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator educated the Maintenance staff on maintaining the fire service backflow tamper switches in accordance with NFPA 101, which includes servicing and maintaining documentation of the fire service backflow tamper switches inspections. The Nursing Home Administrator/Designee will audit appropriate documentation of inspections conducted and quarterly documentation as it relates in accordance with NFPA 101. These audits will be conducted monthly for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring. The facility Administrator/Designee contacted vendor to service the backflow tamper switches. The fire service backflow tamper switches were inspected and tested by a vendor company. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator educated the Maintenance staff on maintaining the fire service backflow tamper switches in accordance with NFPA 101, which includes servicing and maintaining documentation of the fire service backflow tamper switches inspections. The Nursing Home Administrator/Designee will audit appropriate documentation of inspections conducted and quarterly documentation as it relates in accordance with NFPA 101. These audits will be conducted monthly for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring.
Failure to Maintain Fire Sprinkler System per NFPA Standards
Penalty
Summary
The facility failed to maintain its automatic fire sprinkler system (AFSS) in accordance with NFPA 101 and NFPA 25 standards. During a facility tour with the Facility Manager, surveyors observed multiple deficiencies in the sprinkler system, including corroded and dust-loaded sprinkler heads. Specifically, all 14 pendant sprinkler heads in the front porch and exterior covered drive were found to be corroded, as well as 2 of 3 pendant sprinkler heads in the laundry washroom. Additionally, 1 of 2 upright sprinkler heads behind the dryers was corroded, and another upright sprinkler head in the same area was loaded with dust. These findings were confirmed through interviews with the Facility Manager conducted at the time of observation. The report documents that the facility did not meet the required standards for inspection, testing, and maintenance of the AFSS, as outlined in the referenced NFPA codes. No information about residents or their medical conditions is included in the report.
Plan Of Correction
The facility Administrator/Designee contacted a vendor to service the 14 pendant sprinkler heads located at the front porch and cover drive, the 2 pendant sprinkler heads located in the laundry washroom, the 1 upright sprinkler head located behind the dryers, and the 1 sprinkler head covered with dust behind the dryers, as it relates to meeting compliance with NFPA 101. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator educated the Maintenance staff on maintaining sprinkler heads in accordance with NFPA 101, which includes maintaining them free of dust or corrosion. The Nursing Home Administrator/Designee will conduct weekly audits for 3 months on 5 sprinkler heads to ensure they are maintained in accordance with NFPA 101, including being free of dust and corrosion. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring. The facility Administrator/Designee contacted a vendor to service the 14 pendant sprinkler heads located at the front porch and cover drive, the 2 pendant sprinkler heads located in the laundry washroom, the 1 upright sprinkler head located behind the dryers, and the 1 sprinkler head covered with dust behind the dryers, as it relates to meeting compliance with NFPA 101. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator educated the Maintenance staff on maintaining sprinkler heads in accordance with NFPA 101, which includes maintaining them free of dust or corrosion. The Nursing Home Administrator/Designee will conduct weekly audits for 3 months on 5 sprinkler heads to ensure they are maintained in accordance with NFPA 101, including being free of dust and corrosion. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring.
Failure to Provide Required Smoking Safety Equipment
Penalty
Summary
During a facility tour, an employee was observed smoking on the property outside of a designated smoking area. The area where the employee was smoking did not have ashtrays made of noncombustible material and safe design, nor were there metal containers with self-closing cover devices available for ashtray disposal, as required by NFPA 101 and NFPA 1 standards. These observations were confirmed in real time with the Facility Manager. At the exit conference, the administrator stated that the facility has a smoking regulations policy that prohibits smoking anywhere on the property at any time. Despite this policy, the observed smoking incident occurred, and the required smoking safety equipment was not present in the area where the violation took place. No information about residents or their medical conditions was included in the report.
Plan Of Correction
The Staff member was identified and was immediately educated on the facility's non-smoking policy. The nursing home administrator conducted walking rounds of the outdoor areas surrounding the facility as it relates to any concerns with facility adherence to non-smoking policy. No concerns were identified. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator/Designee re-educated facility staff on the non-smoking policy. The Nursing Home Administrator/Designee will conduct a random audit weekly 3 times a week on the facility staff's adherence to the facility's non-smoking policy by visual inspection. These audits will be conducted weekly for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring. The Staff member was identified and was immediately educated on the facility's non-smoking policy. The nursing home administrator conducted walking rounds of the outdoor areas surrounding the facility as it relates to any concerns with facility adherence to non-smoking policy. No concerns were identified. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator/Designee re-educated facility staff on the non-smoking policy. The Nursing Home Administrator/Designee will conduct a random audit weekly 3 times a week on the facility staff's adherence to the facility's non-smoking policy by visual inspection. These audits will be conducted weekly for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring. The corridor door equipped with a self-closing mechanism leading to the clean utility room by the nurse's station was called for servicing and repairs. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator educated the Maintenance staff on maintaining fire doors in working condition, including latching and closing appropriately. The Nursing Home Administrator/Designee will conduct weekly audits on 3 fire doors to ensure they are latching and closing appropriately for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring.
Failure to Maintain Self-Closing Fire Door Mechanism
Penalty
Summary
During a recertification survey, it was observed that the facility failed to maintain fire doors in accordance with NFPA 101 and NFPA 80 standards. Specifically, the corridor door equipped with a self-closing mechanism leading to the clean utility room by the nurse's station did not close or self-latch when tested. This observation was made during a facility tour with the Facility Manager, who confirmed the findings at the time of inspection. The deficiency was identified based on direct observation and interview, with no mention of any specific residents or patient involvement. The report notes that all fire door assemblies are required to be labeled, maintained in a legible condition, and equipped with functioning self-closing or automatic-closing devices. The failure to ensure the door's proper operation constituted noncompliance with the cited NFPA standards.
Plan Of Correction
The corridor door equipped with a self-closing mechanism leading to the clean utility room by the nurse's station was called for servicing and repairs. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator educated the Maintenance staff on maintaining fire doors in working condition, including latching and closing appropriately. The Nursing Home Administrator/Designee will conduct weekly audits on 3 fire doors to ensure they are latching and closing appropriately for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring. The Nursing Home Administrator educated the Maintenance staff on maintaining fire doors in working condition, including latching and closing appropriately. The Nursing Home Administrator/Designee will conduct weekly audits on 3 fire doors to ensure they are latching and closing appropriately for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring.
Inadequate Infection Control Leads to Skin Rash Outbreak
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the ongoing skin rashes among residents and staff. The report highlights that four residents were reviewed for ongoing skin rashes, and it was found that the facility did not ensure proper cleaning and isolation measures. A family member of one resident reported that the resident's room and personal items were not cleaned properly after treatment for a skin condition, leading to a recurrence of symptoms. Additionally, other residents reported similar issues, with complaints of itching and lack of effective treatment or cleaning measures. Interviews with staff revealed that multiple residents across different units were experiencing rashes and itching, yet there were no transmission-based precautions in place. Staff members also reported experiencing similar symptoms, which they treated themselves. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were not fully aware of the extent of the issue, and the facility's infection preventionist had not been tracking the outbreak effectively. The lack of communication and documentation contributed to the failure to address the spread of the condition. The facility's policies on surveillance and treatment of communicable conditions were not followed, as evidenced by the absence of skin scrapings to diagnose the rashes and the lack of deep cleaning in affected areas. The DON and Nursing Home Administrator (NHA) were unaware of the full scope of the issue, and the facility did not consider the situation an outbreak, which would have prompted more rigorous tracking and intervention measures. This oversight led to the continued spread of the condition among residents and staff.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? Residents #5 and #6 diagnosed as possible by Director of Nursing/Preventionist obtained orders on for contact isolation for affected residents #5 and #6. Resident #7 returned from the hospital where she was treated for on Director of Nursing/Preventionist obtained orders upon returning from the hospital, for contact isolation for resident #7. Resident #8 skin clear and free of upon assessment on. Affected rooms were deep cleaned on or before using the deep clean protocol for their room, clothing, and personal items. Preventionist initiated line listings on and notification for residents who have/had rashes that could be indicative of. Preventionist initiated line listings on and notification for staff who have/had rashes that could be indicative of. Preventionist initiated line listings for visitors and notification who have/had rashes that could be indicative of on. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? House Wide Skin sweep completed on or before by nursing leadership to evaluate all residents for a indicative of. As applicable, orders obtained for treatment, transmission-based precautions were initiated, and the deep clean protocol for their room, clothing, and personal items. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? The Director of Nursing provided education to the Preventionist on transmission-based precautions and initiating a line listing for new and/or suspected rashes that could be indicative of. Staff educated, by Director of Nursing/Preventionist/Designee on or before regarding the facility policies and procedures for reporting potentially illness and rashes to Preventionist or Nursing administration for themselves. Director of Nursing/Preventionist/Designee will identify any residents, staff, or visitors ongoing that may have had exposure or at risk of potentially illness to identify if any would require initiating a line listing and/or isolation precaution. Director of Nursing/Preventionist/Designee will monitor documentation and new orders weekly for treatment to identify if any would require initiating a line listing and/or isolation precautions due to a suspicious will. Any residents found with a will undergo a deep cleaning of their room, clothing, and personal items bagged and cleaned as indicated. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be implemented? Director of Nursing or Designee to complete audit to ensure compliance with identification of rashes possibly requiring transmission-based precautions. Audits will be completed 3x weekly for x4 weeks, then twice weekly x4 weeks, then weekly. NHA to review audits monthly for compliance. The DON or will report their findings to the Quality Assurance committee Monthly until such time that substantial compliance has been met.
Failure to Facilitate Timely Care Plan Meeting Notifications
Penalty
Summary
The facility failed to facilitate timely care plan meeting notifications, preventing residents and their representatives from participating in the development and implementation of person-centered care plans. For Resident #6, the facility did not make sufficient attempts to contact the resident's Power of Attorney (POA) for care plan meetings. Despite the resident's severe cognitive impairment, only one attempt was made to contact the POA by mail, and no further attempts were documented. Additionally, there was a lack of documentation for care plan invitations and summaries for several comprehensive assessments, and the last care plan note was dated back to 2021. Resident #17, who had intact cognition, did not receive adequate notification for care plan meetings. The facility mailed an invitation to the POA only six days before a scheduled meeting, and there was no documentation of care plan invitations or summaries for several assessments. The MDS Coordinator stated that the resident did not normally participate in meetings, and the facility only reached out to family members if they expressed interest, which contributed to the lack of resident involvement. For Resident #23, who had moderate cognitive impairment, the facility failed to provide documentation of care plan invitations or summaries for certain quarterly assessments. Although the resident and a family member participated in some meetings, there was no documentation of care plan notes or IDT narrative notes in the clinical record. The MDS Coordinator acknowledged the absence of uploaded summaries and stated that summaries were done with every care plan meeting, but they were not consistently documented in the resident's electronic records.
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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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