Life Care Center Of New Port Richey
Inspection history, citations, penalties and survey trends for this long-term care facility in New Port Richey, Florida.
- Location
- 7400 Trouble Creek Road, New Port Richey, Florida 34653
- CMS Provider Number
- 106049
- Inspections on file
- 17
- Latest survey
- March 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Life Care Center Of New Port Richey during CMS and state inspections, most recent first.
The facility failed to maintain emergency exit doors according to NFPA 101 standards. During a facility tour, it was observed that the exit door by Room 114 did not latch when closed. This was confirmed by the maintenance director, indicating a lapse in the facility's maintenance protocols for door inspections and testing.
The facility failed to address grievances raised by the resident council, including delayed call light responses, staff not wearing name tags, and insufficient staffing. Despite discussions in meetings, these issues were not logged or documented as resolved, contrary to facility policies. Interviews revealed a lack of understanding and execution of the grievance process by the Activities Director and Nursing Home Administrator.
The facility failed to complete or update PASRRs for several residents with mental illness and intellectual disabilities. This oversight affected six residents, whose PASRR documentation was either incomplete or outdated, failing to include necessary diagnoses and evaluations. The facility's policy mandates thorough screening and evaluation, but these procedures were not followed, leading to the identified deficiencies.
The facility failed to ensure competent nursing staff, resulting in multiple deficiencies. A resident with documented allergies was served inappropriate food items, and another had undated bandages. There was also a failure to follow up on a medication order with a black box warning. Additionally, residents were not provided adequate nutrition and hydration, with one resident missing lunch before a medical appointment and others not being offered hydration in the activities room.
A resident experienced a significant weight loss, which was not addressed in their care plan. Despite documented weight loss and meal refusals, the care plan was not updated with new interventions. Staff interviews revealed a lack of communication and coordination, as the resident consistently ate less than 25% of meals, yet this was not effectively communicated or reflected in the care plan.
A facility failed to follow up on a medication order with a black box warning for a resident, resulting in the resident not receiving the medication since admission. Additionally, another resident missed a meal due to an outing, and staff did not provide a meal or snack upon return. Furthermore, a resident was observed without hydration in the activities room, contrary to facility expectations.
A resident experienced a significant weight loss of 10.53%, but the facility failed to complete a timely assessment or update the care plan. Despite the resident's nutritional risk due to advanced age, there was no documented assessment or physician notification. Staff noted the resident's poor meal intake, and the RD confirmed the lack of an updated assessment and interdisciplinary team meeting.
The facility failed to accurately code the MDS assessments for two residents. One resident was incorrectly coded as discharged to home/community instead of the hospital, while another was coded as discharged to a hospital instead of home. The inaccuracies were confirmed by the MDS Coordinator and DON, and the facility lacked a specific policy to address this issue.
A resident experienced a significant weight loss of 10.53%, which was not addressed in their care plan. The facility staff, including a CNA and Diet Technician, were unaware of the weight loss, and the Registered Dietician confirmed that the care plan was not updated with new interventions. The interdisciplinary team did not meet to address the resident's weight loss, and the focus was on the resident's ability to eat independently rather than meal consumption.
The facility failed to maintain adequate hydration and meal provision for residents, as observed in several cases. A resident missed lunch due to a medical appointment and was not provided with food upon return, while two other residents were observed without hydration. Staff interviews revealed a lack of communication and adherence to facility policies on hydration and nutrition, contributing to these deficiencies.
A resident did not receive a prescribed medication with a black box warning due to a lack of follow-up by the facility. The medication was not sent by the pharmacy, and the issue persisted since the resident's admission. The DON contacted the PCP and ARNP, who advised discontinuing the medication. The facility's policy on medication shortages was not adhered to, as the nurses failed to collaborate with the pharmacy and physician for an alternative.
The facility exceeded the acceptable medication error rate, reaching 10.34% due to staff failing to administer the 81 mg Delayed Release medication as ordered to two residents. Despite the facility's policy requiring adherence to the 10 rights of medication administration, errors occurred during observations involving an LPN and an RN, which were later confirmed by the Unit Manager and reported to the DON.
The facility failed to securely store medications, leaving them accessible to unauthorized individuals. Medications, including a custom medication bottle, an inhaler, and creams, were found in residents' rooms without corresponding physician orders for administration or self-administration. The Director of Nursing confirmed that medications should be stored in locked compartments and administered by nursing staff unless a self-administration order is present, which was not the case for the involved residents.
A resident with documented intolerances to milk and wheat was repeatedly served these items, despite requests for alternatives like almond milk. The facility's dietary staff failed to ensure meal tickets reflected the resident's preferences, leading to inappropriate food being served.
Failure to Maintain Emergency Exit Doors
Penalty
Summary
The facility failed to maintain emergency exit doors in accordance with NFPA 101 standards. During a facility tour conducted on March 6, 2025, between 11:30 a.m. and 2:00 p.m., it was observed that the exit door by Room 114 did not latch when in the closed position. This observation was made in the presence of the maintenance director, who confirmed the findings during an interview conducted concurrently with the observations. The deficiency highlights a failure in the facility's maintenance, inspection, and testing of doors, as required by NFPA 101 and NFPA 80 standards. The report indicates that fire door assemblies are to be inspected and tested annually, and non-rated doors should be routinely inspected as part of the facility's maintenance program. However, the failure of the exit door to latch properly suggests a lapse in these maintenance protocols, as the individuals responsible for door inspections and testing are expected to possess the necessary knowledge, training, or experience to ensure compliance.
Plan Of Correction
4/5/25 On March 6, 2025, a security and fire protection company repaired the latch on the exit door by room 114. A facility-wide audit on exit doors was performed by a security and fire protection company on March 6, 2025, with no variances noted. Education was provided to the Maintenance Staff by the Executive Director on March 27, 2025, about NFPA 101 Inspection & Testing Doors per (2012 and 2021 Editions). Monthly audits will be completed by the Maintenance Director or Designee to ensure the exit doors are maintained. These audits will be reviewed in the Quality Assurance Performance Improvement meeting for three months until substantial compliance is met.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to ensure that grievances raised by the resident council were fully and promptly addressed. During a resident council meeting, ten participants confirmed ongoing complaints about delayed responses to call lights, particularly during the third shift, and the lack of staff wearing name tags. Residents also expressed concerns about insufficient staffing, which affected the availability of restorative care, and issues with the facility's cable TV service. Despite these grievances being discussed in meetings, they were not logged in the grievance log or documented as addressed. The resident council meeting minutes revealed several unresolved issues, including the need for staff to wear name tags, education on diets, and the installation of a second rod in closets for wheelchair users. Additionally, residents requested Spanish language lessons due to language barriers with staff. Other concerns included the need for department heads to be identified, visitors not signing in and out, and the absence of garbage bags in restrooms. These grievances were not documented or followed up on, as required by the facility's policies. Interviews with the Activities Director (AD) and the Nursing Home Administrator (NHA) highlighted a lack of understanding and execution of the grievance process. The AD was unaware of the need to initiate grievances from council meetings, while the NHA believed that grievances were addressed promptly and documented. However, the facility's policies on resident council and grievance programs were not adhered to, as grievances were not logged, and resolutions were not communicated effectively to the residents.
Plan Of Correction
On , the Executive Director reviewed the last 3 months of resident council meeting minutes with the Resident Council President and wrote a grievance for the identified concerns. All residents have the potential to be affected. Appropriate notice and invitations were provided for a Resident Council meeting. The Resident Council meeting was held on with, Long Term Care Certified Ombudsman present and residents report satisfaction with facility response to the previously cited grievances. On , the facility Executive Director/Nursing Home Administrator educated the Activities Director on the Resident Council policy and procedures as well as the facility Grievance policy and procedures. A Resident Council concern/grievance follow up form was created and incorporated to ensure that the Executive Director and Resident Council President confirm each month that follow up to grievances brought forth in the Resident Council meeting is appropriate. Results of the Resident Council concern/grievance follow up forms will be tracked and trended and reported monthly to the Quality Assurance Performance Improvement Committee until sustained compliance achieved.
Failure to Complete PASRRs for Residents with Mental and Intellectual Disabilities
Penalty
Summary
The facility failed to complete or update the Pre-admission Screening and Resident Reviews (PASRRs) for residents with mental illness and intellectual disabilities. This deficiency was identified for six residents out of 23 reviewed. The PASRR process is crucial for determining whether individuals with mental or intellectual disabilities require the level of services provided by a nursing facility and if they need specialized services. The facility's oversight in this process led to incomplete or outdated PASRR documentation for these residents. For Resident #12, the Level I PASRR was not revised to include diagnoses of major mental health conditions. Similarly, Resident #57's PASRR was left blank, and qualifying diagnoses were not submitted for consideration. Resident #66's PASRR was incomplete, and a Level II evaluation was not conducted despite qualifying diagnoses. Resident #30's PASRR was also incomplete, with no Level II evaluation submitted. Resident #73's PASRR did not document a qualifying diagnosis, and Resident #84's PASRR was incomplete, lacking a Level II evaluation for consideration of their diagnoses. The facility's policy requires that potential admissions are screened for serious mental or intellectual conditions through a Level I PASRR before admission. A positive Level I screen necessitates a Level II evaluation by the state-designated authority. The facility is responsible for ensuring these screenings are completed and updated as necessary, and for notifying the appropriate state authority when a resident experiences a significant change in their condition. However, the facility failed to adhere to these procedures, resulting in the identified deficiencies.
Plan Of Correction
A new screening was completed on or before for Resident #12, #57, #66, #30, #73, and #84 to accurately capture applicable diagnoses. For any that resulted in Resident Review Evaluation Requests through the Preadmission Screening and Resident Review Form third party vendor, requested documentation has been submitted and is pending third party vendor review. Current residents have the potential to be affected. Current resident Preadmission Screening and Resident Review Forms will be reviewed by to ensure accuracy. For any inaccurate Preadmission Screening and Resident Review Form identified, a new screening will be completed and Resident Review Evaluation Requests through the Preadmission Screening and Resident Review Form third party vendor if applicable. The facility process will be to review new admission Preadmission Screening and Resident Review Forms in the facility clinical meeting and submit revisions or requests for Resident Review Evaluation if applicable. Director of Nursing / Nursing Home Administrator/or Designee will educate Social Services Department staff, Nursing Administration staff, and Admissions Department Staff on Preadmission Screening and Resident Review Form accuracy, specific to ensuring that the Preadmission Screening and Resident Review Form captures applicable diagnoses referenced on the Preadmission Screening and Resident Review Form screening form. Director of Nursing / Nursing Home Administrator/ or Designee will audit 8 Preadmission Screening and Resident Review Forms per week for accuracy. For any inaccurate Preadmission Screening and Resident Review Form identified, a new screening will be completed and Resident Review Evaluation Requests through the Preadmission Screening and Resident Review Form third party vendor if applicable. Results of the audits will be tracked and trended and reported to the monthly QAPI meeting until sustained compliance achieved.
Deficiencies in Nursing Competency and Resident Care
Penalty
Summary
The facility failed to ensure competent staff were available to provide skilled nursing care and services, resulting in multiple deficiencies. One significant issue involved a resident who was served food items containing allergens, specifically wheat and milk, despite having documented allergies to these substances. The dietary staff, including the Certified Dietary Manager and Dietary Aides, acknowledged the error, stating that the resident's meal ticket was not properly reviewed, leading to the resident being served inappropriate food items. The facility was also out of almond milk, which was the resident's preferred alternative, and the family was expected to supply it. Another deficiency was observed with a resident who had undated bandages on their left side, contrary to the facility's policy requiring bandages to be dated and initialed by the nursing staff. This oversight was confirmed by the Director of Nursing and other nursing staff, who acknowledged the importance of dating bandages to track when they were last changed. Additionally, there was a failure to follow up on a physician's order for a medication with a black box warning for another resident. The medication was not administered since admission due to a lack of communication between the facility and the pharmacy, and the nursing staff did not notify the resident's physician to seek further instructions. The facility also failed to provide adequate nutrition and hydration services. One resident was not given lunch before a medical appointment and was not offered any food upon returning to the facility. Furthermore, several residents were observed in the activities room without being offered hydration, and staff were not aware of the residents' hydration needs. The Director of Nursing stated that residents should be offered hydration at least once an hour, and dietary staff should be notified to provide meals or snacks for residents who miss mealtime due to appointments.
Plan Of Correction
Resident # 163 was discharged from the facility. Resident # 66 was assessed with no negative outcome. Resident #73 was changed by our Nurse with no negative outcome. Resident # 91, 16, and 49 were assessed with no negative outcomes. Resident #264 had his medication, (HCI) discontinued by order from the Advanced Registered Nurse Practitioner. Residents with food have the potential to be affected. Residents with food will be reviewed to ensure no related consequences. Residents with have the potential to be affected by not being dated. Residents with will be reviewed to ensure are dated. Residents with medications with black box warnings have the potential to be affected. They will be reviewed to ensure no black box medication related negative effects. Current residents with since will be evaluated for negative consequences from not being provided a meal or snack with a scheduled outing. Residents' whose Activities of Daily Living are dependent on staff that spend time in the activity day rooms for hydration were reviewed to ensure the necessary assistance and fluids are being provided according to the resident needs and plan of care. The Director of Nursing / Staff Development Coordinator will complete training to the Licensed nurses and Certified Nursing Assistants on the process for ensuring food items that residents are to are not accessible, the facilities hydration policy and process with a focus on the residents that are dependent upon staff to meet their hydration needs. The training will also review the process for communicating resident to the kitchen and ensuring residents receive a snack or meal according to resident preferences. The Director of Nursing/ Staff Development Coordinator will educate licensed nurses on the need to ensure are dated and follow up on physician ordered black box warnings is completed timely. The Director of Nursing / Designee will complete 5 random weekly audits of day rooms to ensure residents do not have access to food to verify staff understanding of the education provided. The Director of Nursing/Designee will complete 5 random observations of to ensure they are labeled and 5 random audits of residents with black box warning to ensure physician orders are followed up on. In addition, the Director of Nursing/ Designee will interview 3 residents per week to determine if residents who have have been offered and/or provided a meal or snack and complete 5 random observations of dependent residents in the activity day rooms to ensure they are being provided and assisted with hydration. These audits, interviews and observations will validate staff competency and knowledge of the facility processes. The results of the audits will be tracked, trended and reported to the monthly Quality Assurance Performance improvement meeting until sustained compliance achieved.
Failure to Update Care Plan After Significant Weight Loss
Penalty
Summary
The facility failed to effectively assess and revise a resident's care plan following a significant weight loss for one resident. The resident, identified as #162, experienced a 10.53% weight loss, which was not addressed in the care plan. The care plan, last updated prior to the weight loss, included interventions such as dietician evaluations and medication administration but did not reflect the recent significant weight change. Observations and interviews revealed that the resident had a history of variable intake and meal refusals, which were not adequately addressed. The resident's family noted a significant decrease in the resident's eating habits. Staff interviews indicated that the resident consistently ate less than 25% of meals, yet this was not communicated effectively to the nursing staff or reflected in the care plan. The facility's Registered Dietician confirmed that the resident's significant weight loss was documented but not followed up with appropriate care plan updates or interdisciplinary team meetings. The dietician had recommended supplements, but there was no evidence of a revised care plan or additional interventions to address the resident's nutritional decline. The lack of communication and coordination among staff contributed to the failure to update the resident's care plan appropriately.
Plan Of Correction
The facility residents with significant loss have the potential to be affected by not revising the care plan with changes and new interventions. Residents with a significant loss will be reviewed by the Registered Dietitian/Designee to determine if a significant change assessment and or care plan revision is needed. Revisions and updates will be completed as indicated. The Director of Nursing / Designee will educate the Registered Dietitian, Dietary Tech, Minimum Data Set Coordinators on the need to complete an assessment, and revise the care plan with new interventions for residents with a significant change in status in loss so that the care plan accurately reflects the resident. The Director of Nursing/Designee will complete 3 random weekly audits on loss to determine if the care plan accurately reflects the residents significant loss and/or if revisions are needed. The results of the audits will be tracked, trended and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance achieved.
Medication and ADL Deficiencies in Resident Care
Penalty
Summary
The facility failed to follow up on a physician's order for a medication with a black box warning for one resident. The Director of Nurses (DON) discovered that the resident had not received the medication since admission due to the pharmacy withholding it because of the black box warning. The pharmacy was waiting for a response from the facility, which had not been provided. The DON contacted the Primary Care Provider (PCP), who was uncomfortable making a decision about the medication and advised consulting a specialist. Another deficiency involved the failure to ensure that a resident's activities of daily living (ADLs) were completed and maintained. A Certified Nurses Assistant (CNA) was unsure about the resident's meal schedule and did not provide a snack or meal when the resident missed lunch due to an outing. The resident returned to the facility without having eaten, and staff failed to offer a meal or snack upon her return. The Certified Dietary Manager was not informed of the resident's outing, which would have allowed for meal arrangements to be made. Additionally, a resident was observed in the activities room without hydration for an extended period. Staff interviews revealed that residents should have water available at all times, and hydration should be offered at least once an hour. However, this was not the case for the resident observed. The Director of Nursing expected staff to ensure hydration was available, especially during activities, but this expectation was not met, leading to the deficiency.
Plan Of Correction
Resident #264 had his medication, (HCI) discontinued by order from the Advanced Registered Nurse Practitioner. Residents with black box medication and assisted hydration. Residents whose Activities of Daily Living are dependent on staff for hydration that spend time in the activity rooms were reviewed to ensure the necessary assistance and fluids are being provided while in the activity day rooms. Residents who have scheduled outings have the potential to be affected by not having staff arrange, provide and complete alternative options for meals and/or snacks to accommodate the outing. Current residents with since were evaluated for negative consequences from not being provided a meal or snack with a scheduled outing. The Director of Nursing/Designee in-serviced the licensed and certified nursing staff on the hydration policy including offering and providing assist with fluids, meals and snacks based on the residents' needs and plan of care. This training includes the facility process for residents who have scheduled outings including communicating to the kitchen for timely tray delivery to accommodate the resident needs and preferences with meals, hydration and snacks with the residents on outings as needed. The Dietary Director will educate kitchen staff on the facility process for communicating and accommodating meal or snack delivery for residents with. The Director of Nursing / Designee will complete 5 weekly activity day room observations of residents dependent on staff for hydration to ensure appropriate assist and hydration is being offered to meet the resident's hydration needs.
Failure to Conduct Timely Assessment for Significant Weight Loss
Penalty
Summary
The facility failed to complete a significant change assessment within 14 days for a resident who experienced a notable weight loss. The resident, who was at risk for nutritional decline due to advanced age and other health conditions, showed a 10.53% weight loss. Despite this significant change, there were no documented assessments related to the change in status, and the care plan was not updated accordingly. Observations and interviews revealed that the resident was not eating much, with staff noting that the resident consumed less than 25% of meals. The resident was on a mechanically altered diet with supplements, but there was no evidence of a change in condition being submitted or the physician being notified of the significant weight loss. The Registered Dietician (RD) confirmed that the resident's assessment had not been updated and that the interdisciplinary team had not met to address the resident's significant weight loss. The facility's policy required immediate notification of significant changes in a resident's condition, but this was not followed. The Director of Nursing acknowledged that the physician should have been contacted, and the care plan updated. The failure to conduct a timely assessment and update the care plan represents a deficiency in the facility's compliance with regulatory requirements.
Plan Of Correction
Resident #162 was discharged from the facility. Facility residents with a significant loss are at risk of being affected by not having a significant change assessment. Residents with significant loss were reviewed by the interdisciplinary team to determine if a significant change was indicated. A significant change assessment will be completed if needed. The Director of Nursing/Designee will educate the Minimum Data Set Coordinators, Registered Dietitian, and Dietary Tech on the criteria for determining a significant change with loss and the need to complete a significant change assessment if the criteria is met. The Director of Nursing/Designee will complete 3 random weekly audits on residents with significant loss to determine if a significant change Minimum Data Set assessment was completed. Results of the audits will be tracked and trended and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance achieved.
Inaccurate MDS Coding for Resident Discharges
Penalty
Summary
The facility failed to ensure the comprehensive Minimum Data Set (MDS) assessments were accurately coded for two residents. Resident #108 was admitted with diagnoses including Type 2 diabetes without complications and acute failure with major recurrent, moderate. The MDS for Resident #108 inaccurately indicated a discharge to home/community, while the resident was actually transferred to the hospital for further evaluation and treatment due to increased no output. This discrepancy was identified through a review of the resident's records. Similarly, Resident #110, who was admitted with acute failure and Type 2 diabetes without complications, was inaccurately coded in the MDS as being discharged to a short-term general hospital. However, the discharge summary revealed that Resident #110 was discharged home in stable condition with his daughter. Interviews with the MDS Coordinator and the Director of Nurses confirmed the inaccuracies in the MDS coding for both residents. The facility did not have a specific policy to address this issue, relying instead on the Resident Assessment Instrument (RAI) to ensure accurate MDS coding.
Plan Of Correction
Resident (#108) and Resident (#110) Minimum Data Sets were modified to reflect the accurate discharge status. Residents that were discharged from the facility have the potential to be affected. Residents discharged from the facility in the last 30 days were reviewed by the Minimum Data Set coordinator/ designee to ensure accurate coding of the discharge on the minimum data set. Those found to be inaccurate will be modified to accurately reflect the residents discharge location. The Director of Nursing/Designee provided education to the Minimum Data Set coordinators, Case Manager and Social Service Director on the process for identifying the discharge location and accurate coding of the Minimum Data Set. The Director of Nursing/Designee will complete 3 random weekly audits on discharged residents to ensure residents discharged status was coded accurately. Results of the audits will be tracked and trended and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance achieved.
Failure to Update Care Plan for Significant Weight Loss
Penalty
Summary
The facility failed to effectively assess and revise a resident's care plan following a significant weight loss for one resident. The resident, identified as Resident #162, experienced a 10.53% weight loss, which was not addressed in the care plan. The care plan, last updated prior to the weight loss, included interventions such as dietician evaluations and medication administration but did not reflect the recent significant weight change. Observations and interviews revealed that the resident was not eating much, and family members confirmed the resident's decreased appetite. The facility's staff, including a Certified Nursing Assistant (CNA) and the Diet Technician (DT), were unaware of the resident's significant weight loss. The DT stated that she was responsible for nutritional assessments upon admission but did not know about the resident's weight loss. The Registered Dietician (RD) confirmed that she had documented the weight loss but had not seen the resident in person. The RD acknowledged that the care plan should have been updated with new interventions and that the interdisciplinary team had not met to address the resident's weight loss. Interviews with the Occupational Therapist (OT) revealed that the focus was on the resident's ability to eat independently rather than meal consumption. The OT stated that the dietician would typically communicate with the Director of Rehab (DOR) if there were concerns about weight loss. The facility's policy on comprehensive care plans emphasized the need for timely updates and revisions by an interdisciplinary team, but this was not followed in the case of Resident #162.
Plan Of Correction
Resident # 162 was discharged from the facility. Facility residents with significant loss have the potential to be affected by not revising the care plan with changes and new interventions. Residents with a significant loss will be reviewed by the Registered Dietitian/Designee to determine if a significant change assessment and or care plan revision is needed. Revisions and updates will be completed as indicated. The Director of Nursing/Designee will educate the Registered Dietitian, Dietary Tech, Minimum Data Set Coordinators on the need to complete an assessment, and revise the care plan with new interventions for residents with a significant change in status in loss so that the care plan accurately reflects the resident. The Director of Nursing/Designee will complete 3 random weekly audits on residents with a significant loss to determine if the care plan accurately reflects the residents significant loss and/or if revisions are needed. The results of the audits will be tracked, trended and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance achieved.
Deficiencies in Resident Hydration and Meal Provision
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were adequately maintained for several residents, particularly concerning meals, snacks, and hydration. Resident #91 was observed in various locations without access to hydration and reported not having eaten lunch before a medical appointment. The resident was not provided with food during the appointment or upon returning to the facility, despite staff being aware of the situation. Interviews with staff revealed a lack of communication and coordination regarding the resident's meal arrangements, with the Certified Dietary Manager and nursing staff unaware of the resident's missed meal. Additionally, Resident #16 was observed without hydration while sitting in the activities room. The resident's medical records indicated a need for substantial assistance with eating, and the CNA responsible for the resident was unsure about the frequency of providing hydration. Similarly, Resident #49 was also observed without hydration in the activities room, with medical records showing a need for maximal assistance with eating. Staff interviews highlighted a lack of consistent hydration monitoring, with expectations for hourly checks not being met. The facility's policy on hydration and nutrition requires that residents receive sufficient food and fluids, with hydration always available. However, observations and staff interviews indicated that these procedures were not consistently followed, leading to deficiencies in resident care. The Director of Nursing and Regional Director of Clinical Services acknowledged the lack of monitoring and communication regarding resident hydration and meal arrangements, contributing to the identified deficiencies.
Plan Of Correction
Resident #91 was discharged from the facility. Resident #16 and 49 were assessed with no negative outcomes. Residents that are dependent on staff for hydration that spend time in the activity day rooms are at risk of not being offered and assisted hydration. Residents whose Activities of Daily Living are dependent on staff for hydration that spend time in the activity rooms were reviewed to ensure the necessary assistance and fluids are being provided while in the activity day rooms. Residents who have scheduled outings have the potential to be affected by not having staff arrange, provide, and complete alternative options for meals and/or snacks to accommodate the outing. Current residents were evaluated for negative consequences from not being provided a meal or snack with a scheduled outing. The Director of Nursing/Designee in-serviced the licensed and certified nursing staff on the hydration policy, including offering and providing assistance with fluids, meals, and snacks based on the residents' needs and plan of care. This training includes the facility process for residents who have scheduled outings, including communicating to the kitchen for timely tray delivery to accommodate the residents' needs and preferences with meals, hydration, and snacks during outings as needed. The Dietary Director will educate kitchen staff on the facility process for communicating and accommodating meal or snack delivery for residents. The Director of Nursing/Designee will complete 5 weekly activity day room observations of residents dependent on staff for hydration to ensure appropriate assistance and hydration is being offered to meet the residents' hydration needs. The Director of Nursing/Designee will also complete 3 random weekly interviews and/or observations to ensure residents are being provided an earlier meal/snack or meal/snack upon return based on resident need or preference. Results of the audits will be tracked, trended, and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance is achieved.
Failure to Follow Up on Medication with Black Box Warning
Penalty
Summary
The facility failed to follow up on a physician's order for a medication with a black box warning for a resident. The resident was admitted with a prescription for a medication that was not sent by the pharmacy due to the black box warning. The Licensed Practical Nurse (LPN) noticed the medication was out and placed a STAT order, but the issue had been ongoing since the resident's admission. The Director of Nursing (DON) was informed and contacted the pharmacy, which revealed they were waiting for a response from the facility regarding the black box warning. The DON then reached out to the Primary Care Provider (PCP), who deferred the decision to discontinue the medication to the resident's Advanced Registered Nurse Practitioner (ARNP). The ARNP stated that if contacted earlier, she would have recommended discontinuing the medication upon admission. The facility's policy on medication shortages was not followed, as the nurses did not collaborate with the pharmacy and physician to determine a suitable therapeutic alternative. The pharmacist confirmed that the facility should have contacted them to understand why the medication order was not completed.
Plan Of Correction
Resident #264 had his medication, (HCI) discontinued by order from the Advanced Registered Nurse Practitioner. Residents with black box medication warnings have the potential to be affected by not following up on a physician order. Residents with black box sever interactions were reviewed for any missing, late, ordered or not available medications. Physicians will be notified if indicated. Director of Nursing/Designee will in-service the licensed staff on the facility process if a medication is unavailable from Pharmacy due to formulary coverage, contraindications, drug-drug interactions, drug interaction, black-box warnings or other clinical reason. The facility will collaborate with the Pharmacy and physician/prescriber to determine a suitable therapeutic alternative if needed. This in-service will also have a focus on reporting medications not available in Grand Rounds and in the morning clinical meeting. The Unit Managers/Designee will complete 5 random weekly audits on residents with black box sever interactions to ensure follow up with the physician has been completed and the medication is available if medication is approved for the resident. Results of the audits will be tracked trended and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance achieved.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 10.34% during the survey. This deficiency was identified through observations, record reviews, and interviews involving two residents. Specifically, during a medication administration observation, a Licensed Practical Nurse (LPN) administered several medications to a resident but failed to provide the 81 mg Delayed Release medication as ordered. Similarly, a Registered Nurse (RN) administered medications to another resident but also omitted the 81 mg Delayed Release medication as per the physician's order. The Director of Nursing (DON) was informed of these medication administration concerns by the Unit Manager, who verified the omissions. The facility's policy on medication administration emphasizes adherence to the 10 rights of medication administration, including ensuring the right drug is administered as per the physician's order. However, the staff failed to comply with this policy, leading to the identified medication errors.
Plan Of Correction
Residents #102 and #361 were evaluated for any negative consequences with none noted. The physicians and resident representatives were notified with no new orders received. Facility residents that receive medications have the potential to be affected. The Director of Nursing/Staff Development Coordinator will complete medication administration competencies on each licensed nurse to validate staff competency related to medication administration with focus on preventing medication errors. The Director of Nursing/Staff Development Coordinator will educate licensed nurses on the policy and procedure for medication administration including following physician orders and preventing medical errors. The Director of Nursing/Staff Development Coordinator will complete 5 random weekly medication administration observations to ensure medications are provided as ordered. Observations will be completed on each shift and weekends. Results of the audits will be tracked, trended, and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance is achieved.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored securely and were inaccessible to unauthorized staff, residents, and visitors. During observations, medications were found in the rooms of five residents, including a custom medication bottle, an inhaler, and various creams, none of which had corresponding physician orders for administration or self-administration. These medications were left on bedside tables or in accessible areas, contrary to the facility's policy that requires medications to be stored in locked compartments or administered by nursing staff unless a self-administration assessment is completed. The Director of Nursing confirmed that medications should be stored in treatment or medication carts and administered by nursing staff unless there is a self-administration order, which was not present for any of the residents involved. The facility's policy also mandates that medications should not be left at the bedside and should be securely stored to prevent unauthorized access. The failure to adhere to these protocols resulted in medications being accessible to residents and potentially unauthorized individuals, posing a risk to resident safety.
Plan Of Correction
Residents #265, #63, #12, #164 and #18 medications were removed and properly stored with the permission of the resident or resident representative. Facility residents have the potential to be affected by medications being accessible to unauthorized staff, residents, and visitors. The Director of Nursing and Unit Managers completed 100% observation of each resident's room to ensure medications are not accessible to unauthorized staff, residents, and visitors. Residents that had medications not stored appropriately were removed and stored in the medication carts or residents' locked drawer, if a physician order is in place for self-administration, with the resident or resident representative's permission. The Director of Nursing/Designee will complete 5 random weekly observations of resident rooms to ensure there are no medications that are accessible to unauthorized staff, residents, and visitors. The results of the audits will be tracked, trended, and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance is achieved.
Failure to Accommodate Resident's Food Intolerances
Penalty
Summary
The facility failed to provide food that accommodates a resident's intolerances and preferences, as evidenced by the case of a resident who was served wheat and milk despite having documented intolerances to these items. The resident, who was observed eating breakfast in her room, reported that she had been served wheat and milk on multiple occasions, despite her requests for alternatives such as almond milk. The resident's care plan and physician orders indicated that she should not be served milk or wheat, and that almond milk should be used instead. However, the facility did not have almond milk available at the time, and the resident's meal ticket incorrectly included items she was intolerant to. Interviews with the facility's dietary staff, including the cook, dietary aides, Certified Dietary Manager (CDM), and Diet Technician (DT), revealed a breakdown in communication and responsibility. The dietary aides admitted to errors in reviewing meal tickets, and the CDM acknowledged that the resident was served items she was intolerant to, despite having documented these preferences. The DT confirmed her role in updating meal tickets and expressed confusion over the oversight. The facility's policy on food preferences and intolerances was not effectively implemented, leading to the resident being served inappropriate food items.
Plan Of Correction
Resident #163 was discharged from the facility. Residents with food intolerances and preferences have the potential to be affected by not honoring intolerances and preferences. The Registered Dietician/diet tech will review residents with food intolerances to ensure the residents' tray ticket and care plan are accurate. The diet tech/food service director will interview residents to ensure their food preferences are accurate and are correct on residents' tray tickets. The facility added a food tray checker at the end of the tray line to verify the tray is accurate, honoring the resident's intolerances and food preferences. The Registered Dietitian/Designee will in-service the food and nutrition staff on the process for ensuring residents with intolerances are not served those food items and that food preferences are honored. This training will include the process for checking the tray prior to serving. The Director of Nursing/Designee will in-service licensed nurses, certified nursing assistants, and activity staff on the need to ensure that the items on the tray match the tray ticket and that food items that the residents are to avoid or have intolerances to are not served, and that food preferences are provided. The Registered Dietitian/Designee will complete 5 random weekly meal observations to ensure that residents are not served items they are to avoid or have intolerances to and are provided their food preferences. The results of the audits will be tracked, trended, and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance is achieved.
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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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