Rehab & Healthcare Center Of Cape Coral
Inspection history, citations, penalties and survey trends for this long-term care facility in Cape Coral, Florida.
- Location
- 2629 Del Prado Blvd, Cape Coral, Florida 33904
- CMS Provider Number
- 105342
- Inspections on file
- 23
- Latest survey
- May 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Rehab & Healthcare Center Of Cape Coral during CMS and state inspections, most recent first.
Multiple residents were found with call lights out of reach, including some who were unaware of their location or unable to summon help. Staff confirmed that call lights should be accessible, and some residents reported long wait times for assistance.
Three residents with significant medical needs did not receive scheduled showers or adequate personal hygiene care, as required by their care plans and facility policy. Documentation was incomplete or missing for multiple shifts, and staff interviews confirmed that care was not consistently provided or recorded, resulting in neglect of residents' hygiene needs.
A resident admitted with left-sided weakness following a stroke was evaluated for PT and OT, with orders for therapy six times per week. However, documentation and staff interviews confirmed that the resident did not receive any therapy sessions as ordered during their short stay, and was discharged to the hospital without receiving the required rehabilitative services.
The facility did not maintain its fire alarm system according to NFPA 101 standards, as 18 duct detectors were not tested during a biennial smoke detector sensitivity test. This was confirmed during a record review and staff interview with the Maintenance Director.
A facility failed to follow physician orders for a resident's tube feeding, as a nurse did not check tube placement or flush it before use. Additionally, two residents' medication administrations were not documented accurately, with missing entries in the MAR. An LPN also did not assess pain scores before administering PRN medications, relying instead on visual assessment, contrary to standard practice.
The facility failed to maintain proper infection control practices during care for two residents. Staff were observed not adhering to hygiene protocols, such as not sanitizing hands or changing gloves between tasks, and using unclean equipment during wound care and medication administration. These actions indicate lapses in infection prevention and control measures.
A deficiency was identified involving improper nursing practices and failure to schedule necessary medical appointments. An LPN failed to flush a feeding tube as required, evidenced by a dry syringe found unused. Additionally, a resident with a new medical device was not scheduled for a necessary specialist appointment due to a breakdown in communication and procedure.
The facility failed to maintain a safe and homelike environment due to damaged drywall and chair rails in several resident rooms, which were not repaired despite being reported. The absence of a full-time Maintenance Director for several months contributed to the oversight, as the damage was not documented in the maintenance system.
The facility failed to maintain personal hygiene for several residents, including those with dementia, quadriplegia, and under hospice care. Residents were observed with unkempt appearances, long fingernails with substances underneath, and requests for care that were not promptly addressed. Scheduled showers and personal hygiene care were not consistently documented or provided, indicating a systemic issue in adhering to care plans.
The facility's medication error rate was 13.79%, exceeding the acceptable threshold. Errors included a nurse administering incorrect Lidocaine patch strength, wrong allergy medication, and incorrect Venlafaxine dosage to a resident. Another nurse gave a resident double the prescribed dose of Torsemide. Both nurses acknowledged their errors.
Two residents in a facility were subject to improper infection control practices during wound care. One resident, with pressure wounds and on Enhanced Barrier Precautions, did not have the required gown worn by staff during care. Another resident, with a surgical wound and pressure injury, experienced lapses in aseptic technique by an RN, including using a contaminated wound cleanser and failing to perform hand hygiene. These actions were against the facility's infection control policies.
The facility failed to document nursing staff's response to changes in condition for two residents, leading to deficiencies in care. One resident experienced multiple instances of reported changes, such as increased assistance needed and shortness of breath, without documented nursing evaluations. Another resident requested hospital transfer due to nausea and vomiting, but the nurse did not contact the physician or document an assessment, leading to a delayed transfer. Both cases highlight a failure in addressing and documenting changes in residents' conditions.
The facility failed to maintain a safe and homelike environment due to drywall damage and broken chair rails in several resident rooms. A resident reported the damage had been present for months without repair. The facility lacked a full-time Maintenance Director for several months, and the new Maintenance Director confirmed the damage was not documented in the maintenance system as required.
The facility failed to document and address changes in health conditions for two residents, leading to deficiencies in care. One resident's condition worsened without proper nursing evaluation or emergency response, while another's request for hospital transfer was ignored by a night shift nurse. Additionally, several residents did not receive adequate personal hygiene care, with observations of unkempt hair and overgrown nails. Staff interviews revealed a lack of communication and documentation regarding care refusals.
A resident with a history of smoking and contractures was unable to smoke due to the facility's failure to provide a specialized chair for transport to the smoking area. This led to significant anxiety and withdrawal symptoms for the resident, as the necessary equipment was not available and the smoking evaluation was delayed. Staff interviews revealed a lack of awareness and communication regarding the resident's needs.
A facility failed to create a comprehensive care plan for a resident with significant medical conditions, including contractures in the lower extremities and left hand. Despite the resident being on hospice and having intact cognitive skills, the care plan lacked interventions such as range of motion exercises or the use of splints and pillows. Interviews with staff revealed a lack of documentation and awareness of the resident's needs, and no restorative program was in place to address the contractures.
A facility failed to provide necessary care for a resident with contractures and ROM limitations. Despite the resident's history of hemiplegia and muscle wasting, and being on hospice, there was no care plan addressing these issues. Observations showed the resident in a fetal position without splints or positioning aids, and staff interviews revealed a lack of documentation and awareness. The facility's restorative program was not implemented, and staff lacked education on managing ROM and contractures.
A resident with an indwelling urinary catheter received improper care, as a CNA used incorrect cleaning techniques, wiping from back to front, contrary to facility protocols. Despite previous training, the CNA's actions were initially praised by the DON, who later admitted the care was inadequate, risking infection.
A resident with a feeding tube was found without the required abdominal binder, which was ordered by the physician to prevent the resident from pulling out the tube. Despite the binder being unavailable due to laundry, nursing staff inaccurately documented its application in the Treatment Administration Record. This discrepancy between the physician's orders and the care provided led to a deficiency.
The facility failed to change IV dressings every 7 days for two residents, as required by policy, risking infection. Observations showed outdated dressings, and MARs inaccurately documented changes. Staff confirmed the lapses, with no evidence of resident refusal.
The facility failed to adhere to physician orders for several residents, resulting in deficiencies. A resident was without a required binder, leading to exposure and leakage at a medical site. Another resident received incorrect medication due to a nurse's misunderstanding of medication orders. Additionally, two residents had outdated medical device covers, contrary to physician instructions. The Director of Nursing confirmed these failures and incorrect documentation.
A facility failed to develop a comprehensive care plan for a resident with significant medical conditions, including limitations in range of motion (ROM). The care plan did not address the resident's needs or preferences, and there was no documentation of interventions or use of supportive devices. Interviews with staff revealed a lack of awareness and documentation regarding the resident's needs, and the absence of a restorative program was noted.
The facility failed to maintain its fire alarm system according to NFPA 101 standards. An annual report revealed that 8 of 12 duct detectors were untested due to being unlocatable, and batteries needed replacement. The smoke detector sensitivity inspection was outdated, and the duct detector air stream test was last conducted months prior. The administrator acknowledged these issues, indicating a need for updated testing by their vendor.
The facility failed to conduct fire drills as required by NFPA 101, with altered dates found on fire drill records. The Maintenance Director, new to the facility, did not conduct the drills prior to the survey. The Administrator acknowledged the alterations and planned further investigation. This deficiency could lead to unprepared staff in a fire emergency.
The facility failed to conduct timely inspections and testing of fire doors and fire and smoke dampers as required by NFPA 80 standards. The last maintenance reports for fire and smoke dampers were over four years old, and the fire door inspection report was outdated. The Director of Maintenance acknowledged a backlog in maintenance tasks. This deficiency could lead to the failure of fire and smoke dampers during fire conditions, affecting all smoke compartments and posing a risk to the safety of the facility's occupants.
The facility failed to document post-disaster analysis for one of its required drills, omitting an After Action Report (AAR) necessary for evaluating and improving its Emergency Preparedness Program. This gap was identified during a review, with the Administrator acknowledging the omission and indicating future compliance.
The facility failed to test electrical equipment according to NFPA 99 and NFPA 110 standards, with no records of main and feeder circuit breaker inspections and exercising. The Maintenance Director, new to the facility, acknowledged the lack of documentation. This deficiency could lead to power loss, equipment fires, or electric shock hazards, endangering the facility's occupants.
The facility's Emergency Preparedness Program was found deficient as it included outdated staff information, risking resident safety during emergencies due to potential lack of medical and support staffing.
The facility's Emergency Preparedness Program failed to include a method for sharing occupancy information with authorities, potentially leaving receiving facilities without necessary information for resident transfers. The EP referenced the ESS website, but the Administrator noted plans to update it to use the 'HFRS' resource.
The facility failed to ensure a safe, clean, and comfortable environment for residents, with observations of live insects, damaged flooring, and unclean ice machines. Staff and residents reported frequent sightings of roaches and ineffective extermination efforts. The Administrator and Regional Director of Maintenance were unaware of the extent of the issues, and there was a lack of documentation for cleaning and maintenance tasks.
The facility failed to provide necessary hygiene care for three residents who required assistance with ADLs. One resident did not receive scheduled showers in March and April 2024, another did not receive any scheduled showers during her stay from October to November 2023, and a third resident did not receive any scheduled showers from late April to early May 2024. CNA documentation was inconsistent, and there was no clear policy or responsibility for ensuring showers were completed.
The facility failed to maintain an effective pest control program, resulting in frequent sightings of large roaches and other insects in resident rooms and common areas. Residents and staff reported ongoing issues, and the pest control measures in place were found to be inadequate.
A resident's grievances about broken furniture and a frayed call light were not addressed by the facility. Despite multiple reports and work orders, the issues remained unresolved for several months. The Regional Director of Maintenance and the Administrator confirmed the deficiencies but admitted to a lack of follow-up and oversight.
Call Lights Not Accessible to Residents
Penalty
Summary
The facility failed to ensure reasonable accommodation of residents' needs by not providing call lights within reach for nine of eighteen sampled residents. During an initial tour, multiple residents were observed in their rooms with call lights either hooked to glove racks behind the bed, on the floor, or otherwise out of reach. Some residents were unaware of the location of their call lights, while others were observed calling out for help or unable to summon assistance due to the call light's placement. Photographic evidence was obtained for several rooms, confirming the call lights were not accessible. Staff interviews corroborated these findings, with a registered nurse acknowledging that call lights should be within residents' reach. Several residents reported not knowing where their call lights were or described long wait times for assistance, sometimes up to an hour. The deficiency was observed across multiple rooms and affected both residents who could communicate and those who could not respond to interview questions.
Failure to Provide Scheduled Showers and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary care and services to maintain personal hygiene for three of five sampled residents, resulting in neglect as defined by facility policy. For one resident with a history of cerebral vascular accident and chronic kidney disease, documentation did not show that scheduled showers or personal hygiene assistance were provided as required, with several shifts lacking any record of care. Another resident with alcohol abuse, dementia, and multiple sclerosis was observed with poor oral hygiene and reported not remembering the last time he had a shower, with documentation failing to confirm that scheduled showers were given and several days lacking any record of personal hygiene care. A third resident, dependent on dialysis and with multiple comorbidities, stated he had only received four showers in two years and preferred showers over bed baths, but documentation did not show that scheduled showers were provided on multiple occasions. Staff interviews confirmed that showers are scheduled and should be documented, and that refusals should be recorded with alternative care provided. However, there was no evidence that refusals were consistently documented or that care plans were updated accordingly. The facility lacked a specific policy on ADL care, relying only on documentation instructions for CNAs. These failures resulted in residents not receiving scheduled showers or adequate personal hygiene, as required by their care plans and facility policy.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required by the plan of care for a resident who had been admitted with a diagnosis of cerebral vascular accident resulting in left hemiparesis. The resident's care plan included orders for both Occupational Therapy (OT) and Physical Therapy (PT), with specified goals and a frequency of six times per week for eight weeks. Documentation showed that the resident was evaluated by both PT and OT, but there was no evidence that the resident received any therapy sessions as ordered during their short stay. Notes indicated that therapy was withheld or that the resident did not participate, and the resident was ultimately discharged to the hospital after only a few days in the facility. Interviews with facility staff, including the Rehab Director, confirmed that while evaluations were completed, there was no documentation of actual therapy sessions being provided. The Rehab Director was unable to locate any additional therapy notes and stated that the resident did not receive therapy due to the brief duration of their stay. Family members also reported that the resident did not receive therapy during their time at the facility.
Failure to Test Duct Detectors in Fire Alarm System
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with the National Fire Protection Association (NFPA) 101 standards. During a revisit survey, it was found that the biennial smoke detector sensitivity test, conducted on 56 devices on February 26, 2025, did not include the testing of 18 duct detectors. This oversight was confirmed during a record review and staff interview with the Maintenance Director, who acknowledged the findings. The deficiency highlights the facility's failure to ensure the proper operation of the fire alarm system, which is crucial for preventing delayed alarm activation or failure under hazardous conditions. The lack of documentation for the testing of the duct detectors indicates a gap in the facility's compliance with the NFPA 101 and NFPA 72 standards, which could potentially lead to serious consequences in the event of a fire emergency.
Plan Of Correction
K345 Fire Alarm System Testing and Maintenance 1. The fire alarm inspection was conducted for sensitivity test on ducks and is currently up to date. 2. Completed audit was conducted and any abnormal findings were corrected. 3. A. Vendor has the facility on schedule to do inspection based on F345 B. Education with the maintenance department for K345 4. Monthly audits for K345 will be conducted and findings will be brought to QAPI. K345 Fire Alarm System Testing and Maintenance 1. The fire alarm inspection was conducted for sensitivity test on ducks and is currently up to date. 2. Completed audit was conducted and any abnormal findings were corrected. 3. A. Vendor has the facility on schedule to do inspection based on F345 B. Education with the maintenance department for K345 4. Monthly audits for K345 will be conducted and findings will be brought to QAPI.
Deficiencies in Medication Administration and Tube Feeding Practices
Penalty
Summary
The facility failed to ensure that physician orders were followed for a resident who required nutritional support through a feeding tube. During an observation, a registered nurse did not check the placement of the feeding tube, check for residuals, or flush the tube before starting the feeding. This was confirmed by interviews with the LPN and the Director of Nursing, who stated that it is standard nursing practice to flush the tube before and after use. The nurse involved was noted to have a language barrier and was reportedly nervous during the procedure. Additionally, the facility did not accurately document the administration of physician-ordered medications for two residents. The Medication Administration Record (MAR) for one resident showed missing documentation for several scheduled medications. Interviews with the Director of Nursing and the Unit Manager revealed that the nurse responsible for administering the medications did not document them due to being busy, although she confirmed that the medications were given. The facility's policy requires immediate documentation of medication administration, which was not adhered to in this case. Furthermore, during a medication pass observation, an LPN failed to ask two residents for their pain scores before administering as-needed medications. The MAR for these residents showed that pain scores were documented without actually being assessed. The LPN claimed familiarity with the residents allowed her to assess their pain visually, but this was not in line with standard practice, as confirmed by the visiting Director of Nursing. This lack of proper documentation and assessment was a recurring issue noted during the survey.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #2, 3, 4, 5, 6 were assessed with no negative outcomes noted. B. Competencies for medication administration were completed for current licensed nurses and any new licensed nurse hired. C. Feeding competencies were completed for current licensed nurses and any new licensed nurse hired. D. Licensed nurses will document the medication administration on the Medication Administration Record post-administration. Oncoming nurses will verify off-going nurses' Medication Administration Record report prior to taking report. If any discrepancy is noted, the Director of Nursing will be made aware immediately. E. Staff education on the components of F684; this education will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. A. The Director of Nursing/Designee will audit daily the Medication Administration Record to ensure no medications were missed the day prior and if any were missed that appropriate interventions were done. This audit will continue weekly for four weeks then monthly for one quarter. B. The Director of Nursing/Designee will do random audits of licensed nurses and feeding residents to ensure tube placement is checked prior to administration. This audit will continue weekly for four weeks then monthly for one quarter. C. The Director of Nursing/Designee will...
Infection Control Lapses During Resident Care
Penalty
Summary
The facility failed to maintain appropriate infection prevention and control practices during wound care for two residents. During an observation, the Unit Manager and Director of Nursing (DON) were seen performing wound care on a resident without adhering to proper hygiene protocols. The DON retrieved a pair of scissors from a care cart without cleaning them and placed them on a clean barrier. The Unit Manager used these scissors to cut foam dressings for the resident's skin. Additionally, the DON handled a sock from the floor and placed it on the resident without changing gloves or performing hand hygiene before touching the clean dressing. In another instance, a Registered Nurse (RN) was observed preparing to administer medication via a feeding tube for a resident. The RN did not sanitize her hands before putting on gloves and continued to handle medication supplies after dropping them on the floor. She labeled a medication container and connected new tubing to the resident's feeding tube without changing gloves or sanitizing her hands throughout the process. The facility's lack of specific care policies and failure to adhere to existing infection control protocols contributed to these deficiencies. The observations revealed lapses in hand hygiene, improper handling of medical equipment, and inadequate use of personal protective equipment, which are critical components of infection prevention and control in a healthcare setting.
Plan Of Correction
F 880- Prevention & Control 1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #1 and 6 have had no negative outcomes. 2: How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; A. A complete audit of residents with care and feeding was done to ensure appropriate orders and interventions are in place and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. The Director of Nursing and Unit Managers were educated on control and proper change procedure. B. License nurses were educated on proper feeding administration and change procedures/techniques. C. Competencies for changes are completed on current license nurses and will be completed on any new license nurses hired. D. Nursing Managers will do weekly rounds to ensure appropriate treatment and healing of is followed. E. Education of staff on the components of F880 this will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. A. The Director of Nursing/Designee will do random audits of care, and feeding administration to ensure proper procedure/techniques are being utilized weekly for four weeks then monthly for one quarter. B. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Deficiency in Nursing Practice and Medical Appointment Scheduling
Penalty
Summary
The deficiency involves improper handling and documentation of medical procedures and orders for residents in the facility. Staff D, an LPN, highlighted a failure to adhere to standard nursing practices, specifically regarding the flushing of feeding tubes. It was noted that a syringe, which should have been used for flushing, was found dry and unused in a Styrofoam cup, indicating that the procedure may not have been performed as required. This was corroborated by Staff F, another LPN, who confirmed that the standard practice is to flush the tube before and after use. The Director of Nursing attempted to address the issue by educating the involved nurse, who claimed to have flushed the tube, but the physical evidence suggested otherwise. Additionally, there was a failure in scheduling and documenting necessary medical appointments for a resident who had a new medical device placed prior to their arrival at the facility. Staff E, an RN, and Staff D, an LPN, both confirmed that there was no record of the resident being scheduled to see a specialist, despite an order being present in the resident's chart. This oversight was attributed to a breakdown in communication and procedure, as the medical records clerk was not informed of the need to schedule the appointment, and the order was not followed up on in a timely manner.
Plan Of Correction
4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. A. The Director of Nursing/Designee will audit daily the Medication Administration Record to ensure no medications were missed the day prior and if any were missed that appropriate interventions were done. This audit will continue weekly for four weeks then monthly for one quarter. B. The Director of Nursing/Designee will do random audits of licensed nurses and feeding residents to ensure tube placement is checked prior to administration of the medication. This audit will continue weekly for four weeks then monthly for one quarter. C. The Director of Nursing/Designee will do random audits of licensed nurses during medication administration to residents to ensure an accurate scale is obtained and documented. This audit will continue weekly for four weeks then monthly for one quarter. D. The Director of Nursing/Designee will submit a report of the findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Facility Fails to Maintain Safe and Homelike Environment Due to Maintenance Oversight
Penalty
Summary
The facility failed to provide a safe, sanitary, and homelike environment for residents on Unit 1, as evidenced by damage to drywall and chair rails in 8 out of 31 rooms. Observations during an initial tour revealed that the drywall and chair-rails behind residents' beds in rooms 6, 9, 14, 18, 21, 35, 37, and 39 were damaged, with chair-rails found on the floor. Additionally, holes were observed in the drywall next to the bathroom doors in rooms 6, 9, 14, 21, and 39. A resident reported that the damage had been present for several months and that staff had been informed, but no repairs had been made. The facility had been without a full-time Maintenance Director for several months, and the newly hired Maintenance Director confirmed the damage during a tour. The Maintenance Director noted that the damage was not documented in the facility's maintenance computer system as required by their Work Orders policy. The Administrator confirmed the absence of a full-time Maintenance Director and acknowledged that the responsibilities of the Maintenance Director included ensuring minor repairs and supervising day-to-day maintenance to prevent deterioration of the facility's physical condition.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. # ,18,21,35,37,39 findings were fixed and addressed. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: A. A Complete audit of all room was conducted, and findings were noted and put on a schedule to be completed. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. Staff was educated on the TELS system. B. Facility Maintenance department and the staff was educated on the components of F584. C. The Maintenance director will check the TELS system daily. D. During morning meeting any environmental concerns will be relayed. E. Department heads concierge rounds were added to report any environmental concerns. F. Education on the components of F584 will be provided annually and upon new hires. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Nursing Home Administrator/Designee will audit the Tels system for timely resolution of work orders along with random room rounds to ensure adequate safe environment is maintained weekly for four weeks then monthly for one quarter. The Nursing Home Administrator/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Failure to Maintain Personal Hygiene for Residents
Penalty
Summary
The facility failed to provide necessary care and services to maintain personal hygiene for several residents, as observed and documented in the report. Resident #24, who was readmitted with diagnoses including dementia and anxiety, required substantial assistance with personal hygiene. Despite this, the resident was observed with greasy, matted hair, long fingernails with a brown and black substance underneath, and a pungent body odor. The resident repeatedly requested a diaper change, but the call light was on the floor, and the request was not promptly addressed by the staff. Resident #69, diagnosed with quadriplegia and anxiety, was dependent on staff for showers and personal hygiene. The resident's fingernails were observed to be long with a brown substance underneath, and the resident expressed an inability to cut them himself. Despite the resident's dependency, there was no documentation of care being provided or refusals being recorded, indicating a lack of adherence to the care plan. Resident #72, who was under hospice care with severely impaired cognitive skills, required total assistance for ADLs. The resident was observed with unkempt appearance, facial hair growth, and long fingernails with a brown substance. Scheduled showers were not documented as provided, and refusals were not consistently recorded. Similarly, Resident #83, also under hospice care, was observed with greasy, matted hair, long fingernails, and a need for water and a change of clothes. The resident's refusals of care were not documented, and the staff failed to provide necessary hygiene care. Resident #271 expressed a desire for a shower and shave, but there was no documentation of care being provided or refusals being recorded, highlighting a systemic issue in maintaining personal hygiene for residents.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. #24, grooming was completed, #69, nails were cut, #271, was shaved and showered, #72, was shaved and cut and clean, #83 was shaved, and were cut and cleaned. B. Rn staff J, CNA staff G, Unit Manager staff E, CNA staff C, CAN staff A, ADON, LPN staff W, Unit manager LPN staff M, CNA staff Q and CNA staff O were all educated on F677. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. A complete audit was done on all residents for proper grooming and ADL care and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. Licensed staff was educated on the components of F677. B. Nursing managers will review POC documentation the following business day for any refusal and completion of ADL care and follow up as needed. C. Nursing managers will review 24-hour report for any refusal or care and follow up as needed. D. Licensed staff was educated on documentation of care provided and refusal of care. E. Concierge rounds will include resident appearance, and any abnormal findings will be brought to morning stand up for further follow up. F. Education on F677 will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will audit the resident appearance and random audits of the 24-hour report and POC for documentation weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter. F 677
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 13.79% during the observation of 29 medication administration opportunities involving five residents and four nurses. One significant error involved RN Staff R, who administered medications to a resident without adhering to the physician's orders. Specifically, RN Staff R applied Lidocaine patches with a 5% concentration instead of the prescribed 4%, administered Loratadine 10 mg without a physician's order instead of the prescribed Cetirizine 10 mg, and failed to administer the correct dosage of Venlafaxine, omitting the additional 37.5 mg required to meet the total prescribed dose of 112.5 mg. Another error was observed with RN Staff K, who administered Torsemide 10 mg to a resident instead of the prescribed 5 mg for the treatment of Congestive Heart Failure and edema. Both nurses acknowledged their errors during interviews, with RN Staff R expressing confusion between Loratadine and Cetirizine and not realizing the discrepancy in Lidocaine patch strength. These errors highlight a lack of adherence to physician orders and medication administration protocols, contributing to the facility's elevated medication error rate.
Plan Of Correction
A. License Nurses was educated on F759 documentation and medication administration. This education will be provided annually and upon new hire orientation. B. Nursing Managers will audit medication administration for any documentation of such as but not limited to not available, holes/blanks in the MAR, and ensure that appropriate follow-up was completed. C. Medication competency was completed for current license nurses and any new license nurse hired. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will do random audits of license nurses during medication administration to ensure proper procedure/techniques is being utilized weekly for four weeks, then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Infection Control Deficiencies in Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care for two residents, leading to deficiencies in infection prevention and control. Resident #53, who had a medical history of senile degeneration, dementia, weight loss, and pressure wounds, was on Enhanced Barrier Precautions (EBP) due to her condition. Despite the presence of signs indicating the need for gown and gloves, Licensed Practical Nurse (LPN) Staff M and Registered Nurse (RN) Staff L only used gloves during wound care, acknowledging afterward that gowns should have been worn as per the EBP policy. Resident #107, who was bedbound and dependent on staff for all activities of daily living, had a surgical wound and a stage 3 pressure injury. During wound care, RN Staff K failed to maintain aseptic technique by using a bottle of wound cleanser that had fallen on the floor, not changing gloves after touching personal items, and not performing hand hygiene between tasks. These actions were contrary to the facility's aseptic dressing change protocol, which requires hand hygiene and glove changes between different stages of wound care. The Director of Nursing and the Regional DON confirmed that the facility's policy required the use of gowns and gloves during wound care under EBP. The Assistant Director of Nursing also acknowledged that using a contaminated bottle of wound cleanser was unacceptable. These lapses in infection control practices placed the residents at risk for potential wound infections, as noted by RN Staff K during an interview.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #53 and Resident #107 had no negative outcome. B. LPN staff M, RN staff L, RN staff K, and evening supervisor staff B was educated on control and proper change procedure. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete Audit of resident with care to ensure appropriate orders and interventions are in place and any abnormal findings was corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. License nurses was educated on proper change procedure/technique. B. Competency for change completed on current license nurses and will be completed on any new License nurse hire. Nursing managers to do weekly rounds to ensure appropriate treatment and healing of is followed. Education of staff on the components of F880 this will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will do random audits of care to ensure proper procedure/techniques is being utilized weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Failure to Document and Address Changes in Resident Conditions
Penalty
Summary
The facility failed to document nursing staff's response to reported changes in condition for two residents, leading to deficiencies in care. Resident #46 experienced multiple instances where staff observed and reported changes in his condition, such as increased assistance needed for transfers, shortness of breath, and confusion. Despite these observations, there was a lack of documented nursing evaluations or actions taken in response to these reports. The Director of Nursing acknowledged the absence of documentation and noted that the resident should have been assessed and the physician notified. Resident #66 also experienced a deficiency in care when she requested to be transferred to the hospital due to nausea and vomiting. Despite her request and symptoms, RN Staff X did not contact the physician or document an assessment. The resident's condition worsened, and she was eventually transferred to the hospital the following day after being seen by a practitioner. The Risk Manager was unaware of the incident until later, and RN Staff X was suspended pending investigation. Both cases highlight a failure in the facility's process for addressing and documenting changes in residents' conditions. The lack of timely nursing assessments and communication with physicians contributed to delays in appropriate care and interventions for the residents involved.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #66 and resident #46 are no longer in the facility. B. PTA staff F, COTA staff Y, LPN staff W, staff AA, CNA staff N, RN staff R, PTA staff Z, Evening supervisor RN staff B, RN staff X, LPN staff M was educated on F684. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: A. A complete audit of residents with a change of condition and residents requesting to go to the hospital was completed and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. Licensed nurses were educated on resident requests to be sent to the hospital and documentation of change in condition. B. Nursing managers will review the 24-hour report the following morning for any documentation of change in condition to ensure appropriate interventions were taken, including but not limited to sending the resident out to the hospital. C. All concerns of change in condition will be brought to the morning meeting for follow-up by the nurse management team. D. Licensed nurses will document and assess any concerns brought to them by any staff members regarding a change in condition, and they must notify the physician in a timely manner to obtain further interventions. If nurses are unable to get ahold of the physician, they can contact the medical director. In an emergent case, such as distress, licensed nurses will call 911 and have the resident sent to the hospital, then document entirely on the findings and interventions. E. Staff will use the INTERACT Stop and Watch program/form to relay any change in condition noted by any resident at the facility. A copy of the Stop and Watch form will also be brought to the morning clinical meeting to be reviewed by nurse managers/ADT to ensure appropriate measures were taken and followed. F. Staff education on the components of F684 will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will audit the follow-up for any change of condition or request to go to the hospital to ensure timely assessment, documentation, and notification is obtained. The audit communication for change in condition will occur weekly for four weeks, then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance, and Compliance Committee monthly for one quarter.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment as required by regulations. Observations during an initial tour of Unit 1 revealed drywall damage and broken chair rails in several resident rooms, specifically rooms 18, 21, 35, 37, and 39. Holes were also noted in the drywall next to the bathroom doors in rooms 21 and 39. A resident reported that the chair rail molding behind beds had been damaged for several months and that staff had been informed, but no repairs had been made. The facility had been without a full-time Maintenance Director for several months, and the newly hired Maintenance Director confirmed the damage during a tour. The Maintenance Director also noted that the damage was not documented in the facility's maintenance computer system as required by their policy. The Administrator confirmed the absence of a full-time Maintenance Director and acknowledged the responsibility of the Maintenance Director to ensure minor repairs and day-to-day maintenance to prevent deterioration of the facility's physical condition.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. # 18,21,35,37,39 findings were fixed and addressed. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. A Complete audit of all room was conducted, and findings were noted and put on a schedule to be completed. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. Staff was educated on the TELS system. B. Facility Maintenance department and the staff was educated on the components of F584. C. The Maintenance director will check the TEL.S system daily. D. During morning meeting any environmental concerns will be relayed. Department heads concierge rounds were added to report any environmental concerns. E. Education on the components of F584 will be provided annually and upon new hires. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Nursing Home Administrator/Designee will audit the Tels system for timely resolution of work orders along with random room rounds to ensure adequate safe environment is maintained weekly for four weeks then monthly for one quarter. The Nursing Home Administrator/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Deficiencies in Health Care and Personal Hygiene Documentation
Penalty
Summary
The facility failed to adequately document and address changes in the health conditions of two residents, leading to a deficiency in providing appropriate health care. For one resident, multiple staff members, including a Certified Occupational Assistant and a Physical Therapy Assistant, reported changes in the resident's condition, such as not feeling well and being unable to obtain clear vital signs. Despite these reports, there was a lack of documentation of a nursing evaluation or appropriate response, such as calling 911 when the resident's condition appeared critical. The Director of Nursing acknowledged the absence of documentation and the need for a proper assessment. Another resident requested to be transferred to the hospital due to feeling unwell, but the request was not acted upon by the night shift nurse, who failed to contact a physician or document an assessment. The resident expressed dissatisfaction with the care received and was eventually transferred to the hospital the following day after a practitioner deemed the resident medically unstable. The facility's risk manager was unaware of the incident until later, and the nurse involved was suspended pending investigation. Additionally, the facility did not maintain personal hygiene for several residents, as evidenced by observations of residents with long, unkempt hair, overgrown nails, and body odor. The facility's policy required showers twice a week, but documentation showed inconsistencies in providing scheduled showers and personal care. Staff interviews revealed a lack of communication and documentation regarding residents' refusals of care, contributing to the deficiency in maintaining personal hygiene.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: A. #24. grooming was completed, #69, nails were cut, #271, was shaved and showered, #72, was shaved and cut and clean, #83 was shaved, and were cut and cleaned. B. Rn staff J, CNA staff G, Unit Manager staff E, CNA staff C, CAN staff A, ADON, LPN staff W, Unit manager LPN staff M CNA staff Q and CNA staff O were all educated on F677. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: A. A Complete audit were done on all resident for proper grooming and adi care and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. License staff was educated on the components of F677. B. Nursing managers will review POC documentation the following business day for any refusal and completion of ADL care and follow up as needed. C. Nursing managers will review 24-hour report for any refusal or care and follow up as needed. D. License staff was educated on documentation of care provided and refusal of care. E. Concierge rounds will include resident appearance, and any abnormal findings will be brought to morning stand up for further follow up. F. Education on F677 will be provided annually and upon new hire orientation. What systematic changes you will make to ensure that the deficient practice does not recur: A. License nurses was educated on resident request to be sent to the hospital and documentation of change in condition. B. Nursing managers will review 24 hour report the following morning for any documentation of change in condition to ensure appropriate interventions were taken including but not limited to sending the resident out to the hospital. C. is to bring all concerns of change in condition to the morning meeting for re follow up by the nurse management team. D. License nurses will document and assess any concerns brought to them by any staff members regarding a change in condition and they must notify physician in a timely manner to obtain further interventions and if nurses are unable to get ahold of the physician they can contact the medical director. If in an emergent case such as distress, or license nurses will call 911 and have resident sent to the hospital and then document entirely on the findings and interventions. E. Staff will use the interact stop and watch program/ form to relay any change in condition noted by any resident at the facility. A copy of the stop and watch form will also be brought to morning clinical meeting to be reviewed by nurse managers/IDT to ensure appropriate measures were taken and followed. F. Staff education on the components of F684 this education will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing /Designee will audit the follow up for any change of condition or request to go to the hospital to ensure timely assessment, documentation and notification is obtained and audit communication for change in condition weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Failure to Accommodate Resident's Smoking Needs
Penalty
Summary
The facility failed to accommodate the smoking needs and preferences of a resident who required a specialized chair for transport to the designated smoking area. The resident, who had a history of smoking and was not interested in a smoking cessation program, was unable to smoke due to the absence of the necessary equipment. This situation caused the resident significant anxiety and withdrawal symptoms, as she was unable to leave her room to smoke. The resident was admitted to the facility with a history of right cerebrovascular accident (CVA) with left side affected, hypertension, atrial fibrillation, and depression. Upon admission, it was noted that the resident had contractures and required a specialized chair for mobility. Despite this, the facility did not have the appropriate equipment available, and the resident's smoking evaluation was delayed. The resident expressed her distress and withdrawal symptoms to staff, but the issue remained unresolved for several days. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's needs. The Nursing Home Administrator and other staff members were not informed of the requirement for a specialized chair, and the resident's smoking evaluation was not completed in a timely manner. The facility's failure to provide the necessary equipment and support resulted in the resident's inability to smoke, leading to unnecessary anxiety and distress.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #470 was assessed, and appropriate chair was provided, smoking assessment completed. B. Education was given to CNA O, SSD, LPN W, Admission Director, Unit manager LPN M. C. Director of Rehab is no longer at the facility. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Audit of all current residents who want to smoke and who currently smokes was completed to ensure they are able to smoke and abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. Education to staff regarding the components of F558. B. Nursing management is to review new admission the following business day to ensure resident who wants to smoke has accommodation to do so. C. Nursing managers will review 24 hour report for any documentation or changes to resident smoking preferences. D. Education for smoking accommodation and F558 will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of nursing/Designee will audit the 24 hour report and review new smoking residents for accommodation and assessment weekly for four weeks then monthly for one quarter. The Nursing Home Administrator/Director of nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Failure to Develop Comprehensive Care Plan for Resident with Contractures
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident, identified as Resident #83, who was on hospice services and had significant medical conditions including hemiplegia, hemiparesis, anxiety, major depressive disorder, and muscle wasting. The resident was observed in a fetal position with contractures in his lower extremities and left hand, yet there were no splints or positioning devices in place to assist with his condition. Despite the resident's cognitive skills being intact, the care plan did not address the management of his contractures or include interventions such as range of motion exercises or the use of splints and pillows. Interviews with facility staff, including the Director of Rehab, Registered Nurse Staff B, the Director of Nursing, and Care Plan Coordinators, revealed a lack of documentation and awareness regarding the resident's contractures and the absence of a restorative program. The staff confirmed that there was no care plan addressing the resident's lower leg contractures, and no documentation of therapy or interventions for the resident's condition. The facility's failure to document and implement a care plan for the resident's contractures was evident, as staff were unaware of the resident's needs and there was no evidence of education provided to direct care staff on how to manage the resident's condition.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. #83 care plan was updated to reflect resident current status. B. Education for F656 provided to RN staff B, care plan coordinator Staff L and Care plan coordinator RN staff H. C. Director of Rehab is no longer at the facility. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete Audit of resident with contractors and limited ROM was conducted and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. License staff was educated on the components of F656. B. Nursing management will review 24 hour report and follow up on any new limited ROM or contractors and update care plan as needed. C. All New residents will be reviewed and reassessed if needed and review by the IDT team the following business day for any limited ROM or contractors to ensure appropriate interventions are in place. D. Education on F656 will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Care Plans /Designee will audit new residents chart and any change of condition charts to ensure that care plans are appropriate to reflect the status of the resident with emphasis on contractor or limited ROM weekly for four weeks then monthly for one quarter. The Director of Care Plans/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Failure to Address Contractures and ROM Limitations
Penalty
Summary
The facility failed to provide appropriate services and interventions for a resident with contractures and limitations in range of motion (ROM). The resident, a male with a history of hemiplegia, hemiparesis, anxiety, major depressive disorder, and muscle wasting, was on hospice services. Despite being identified as having limitations in ROM in both lower extremities and one upper extremity, the facility did not implement a care plan to address these issues. Observations revealed the resident in a fetal position with no splinting devices or positioning aids in place, and staff interviews confirmed a lack of documentation and awareness regarding the resident's contractures. The resident had previously been on and off therapy caseloads, but consistently refused evaluations and services. Occupational and physical therapy records indicated attempts to manage the resident's condition with splints and exercises, but these were met with resistance from the resident. Despite the resident's refusal, there was no documentation of these refusals or any alternative strategies to manage the contractures. Interviews with staff, including the Director of Rehab and the Director of Nursing, revealed a lack of communication and coordination in addressing the resident's needs. The facility's policy on Restorative Nursing Programs was not effectively implemented, as there was no restorative program in place, and staff had not received education on ROM, contractures, or splints. The care plan coordinator confirmed the absence of a care plan for the resident's lower leg contractures, and the Director of Nursing was unaware of the resident's condition. The lack of a coordinated approach and documentation contributed to the failure to provide necessary care for the resident's contractures and ROM limitations.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. #83 was assessed, and care plan was updated. B. RN unit manager E, Hospice CNA, RN staff B, CNA staff C, care plan coordinator Staff 1, CNA staff A, RN care plan coordinator staff H was educated. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete audit of resident with Limited ROM and was completed any abnormal findings was corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. License staff was educated on the documentation of refusal of care, limited ROM and B. Nursing management will review 24-hour report for any refusal of care documentation and ensure and or contractor management are being followed and follow up with any concerns noted. C. Nurse managers will review POC (point of Care) documentation for any refusal or blanks and follow up as needed. D. Nurse Managers will review new admitted residents the following day for any limited ROM and or contractors and ensure appropriate interventions are in place. E. Education for F688 will be provided annually and upon new hire orientation. F. Resident will be screen upon admission and then quarterly by for any decrease in ROM or contractors and appropriate interventions and care plans will be put in place for those residents identified. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will audit identified residents with limited ROM or contractors to ensure adequate interventions are followed weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Improper Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections for a resident with an indwelling urinary catheter. The resident, who had a history of recurrent urinary tract infections and was on antibiotics and prophylactic methenamine, was observed receiving improper catheter care. During the care, a CNA used soapy water from a hand soap dispenser and did not follow the correct procedure for cleaning, wiping from back to front instead of front to back, which is against the facility's protocol. The Director of Nursing initially praised the CNA's performance, but later acknowledged that the care provided did not adhere to the facility's guidelines, placing the resident at risk for infection. The CNA had previously completed competency training and attended an in-service on perineal and catheter care, yet failed to apply the correct techniques during the observed care session.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #107 has no complication with her. B. CNA staff BB and CNA staff CC was reeducated on F590 and care. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete Audit of resident with to ensure appropriate interventions are in place and any abnormal findings were corrected. B. Audit of CNA competency for care completed and any abnormal findings was corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. License staff was educated on care. B. Competency for care was completed for current CNADs and will be obtained for any new hires. C. Education on F690 will be completed for staff, upon new hire orientation and annually. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will do random audits of care to ensure proper procedure/techniques is being utilized weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Failure to Apply Abdominal Binder for Resident with Feeding Tube
Penalty
Summary
The facility failed to adhere to physician's orders regarding the use of an abdominal binder for a resident with a feeding tube, leading to a deficiency. Resident #26, who was readmitted to the facility with conditions including dysphagia and delusional disorders, had a history of pulling out her feeding tube. The physician's order required an abdominal binder to be in place to prevent the resident from pulling out the tube, with instructions to remove it only for skin integrity checks and feeding tube care every shift. However, during observations, the resident was found without the abdominal binder, and the feeding tube was exposed and leaking. Despite the absence of the abdominal binder, the Treatment Administration Record (TAR) was signed by nursing staff, indicating that the binder was applied as per the physician's order. Staff interviews revealed that the binder was unavailable as it was sent to the laundry, and alternative measures such as using a sheet were employed. The RN Unit Manager confirmed that the binder was not applied as ordered, and the documentation on the TAR was inaccurate. This discrepancy between the physician's orders and the actual care provided, along with inaccurate documentation, led to the deficiency identified in the report.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #26 binder use was corrected. B. RN staff K educated on documentation. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete audit of resident and any specialty device used for their tube was completed and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. License Nurses was educated on documentation with emphasis on services not provided/physician orders not carried out and the process of documentation. B. Nurse Manager to review 24 hour report and order detail summary the following business day for any refusal or care, supplies not available and any new order for specialty equipment and follow up to ensure appropriate interventions were implemented. C. Staff was educated on the components of F693 and this education will be provided upon new hire orientation and annually. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will do random audits of resident and any specialty equipment used on their is being utilized weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Failure to Change IV Dressings Timely
Penalty
Summary
The facility failed to ensure the timely change of short peripheral catheter cover dressings for two residents, leading to a potential risk of local and systemic infection. The policy for Vascular Access Devices and Infusion Therapy Procedures requires that short peripheral catheter dressings be changed every 7 days or when the integrity of the dressing is compromised. However, observations revealed that the dressing for one resident was dated 1/22, and for another resident, it was dated 1/31, both exceeding the 7-day requirement. The Medication Administration Records (MAR) for both residents inaccurately documented that the dressings were changed according to the schedule, despite evidence to the contrary. Interviews with staff, including an LPN Supervisor and the Director of Nursing (DON), confirmed that the dressings were not changed as per the physician's orders and facility policy. The DON acknowledged that the MARs were incorrect and that the nurses documented completion of dressing changes that were not performed. There was no documentation indicating that either resident refused the dressing changes, suggesting a lapse in adherence to the established protocols for IV catheter care.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #271 and #23 was changed. B. LPN staff V was educated on change. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete Audit of resident with lines and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. License Nurses was educated on changes. B. Nursing Management will review 24-hour report and order listing report for any new placement and any refusal of care related to change and follow up to ensure appropriate interventions are being followed. C. License nurses was educated on F694, documentation of care and services provided and refusal of care and services, this education will also be provided during new hire orientation and annually. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will do audits of resident receiving 's has received their change weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter. 1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. RN staff R and RN staff K was educated on medication administration. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Audit was completed to ensure residents was receiving correct medications and abnormal finding was corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur:
Failure to Follow Physician Orders and Medication Errors
Penalty
Summary
The facility failed to follow physician orders for multiple residents, leading to several deficiencies. Resident #26 was observed without a required binder, which was supposed to be applied to prevent her from pulling out a medical device. Despite the absence of the binder, the Treatment Administration Record (TAR) was signed off by nursing staff as if the binder had been applied. The binder was reportedly sent to the laundry, and alternative measures were inadequately implemented, resulting in the resident being exposed and the insertion site leaking. Resident #470 received incorrect medication administration, where the nurse administered a medication not ordered by the physician and failed to administer the correct dosage of another medication. The nurse was unaware of the differences in medication strengths and mistakenly believed two medications were the same. This error was confirmed during an interview with the nurse, who acknowledged the mistake in medication administration. Residents #271 and #23 had issues with the timely changing of their medical device covers. The covers were not changed as per the physician's orders, which required changes every seven days. The Medication Administration Records (MAR) inaccurately reflected that the covers were changed, despite photographic evidence and staff interviews confirming otherwise. The Director of Nursing acknowledged the failure to follow physician orders and the incorrect documentation in the MARs.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: A. RN staff R and RN staff K was educated on medication administration. B. Residents #26, #23, #271, #470 and #60 no negative outcome was noted. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Audit was completed to ensure residents was receiving correct medications and abnormal finding was corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. License Nurses was educated on F759 documentation and medication administration this education will be provided annually and upon new hire orientation. B. Nursing Managers will audit medication administration for any documentation of such as but not limited to not available, holes/blanks in the MAR and ensure that appropriate follow up was completed. C. Medication competency was completed for current license nurses and any new license nurse hired. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will do random audits of license nurses during medication administration to ensure proper procedure/techniques is being utilized weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter. 1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: A. Resident #26 binder use was corrected. B. RN staff K educated on documentation. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete audit of resident and any specialty device used for their tube was completed and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. License Nurses was educated on documentation with emphasis on services not provided/ physician orders not carried out and the process of documentation. B. Nurse Manager to review 24 hour report and order detail summary the following business day for any refusal or care, supplies not available and any new order for specialty equipment and follow up to ensure appropriate interventions were implemented. C. Staff was educated on the competence of F693 and this education will be provided upon new hire orientation and annually. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will do random audits of resident and any specialty equipment used on their is being utilized weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter. 1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #271 and #23 was changed. B. LPN staff V was educated on change. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete Audit of resident with lines and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. License Nurses was educated on changes. B. Nursing Management will review 24-hour report and order listing report for any new placement and any refusal of care related to change and follow up to ensure appropriate interventions are being followed. C. License nurses was educated on F694, documentation of care and services provided and refusal of care and services, this education will also be provided during new hire orientation and annually. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will do audits of resident receiving s has received their change weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for Resident #83, as required by the regulation. The care plan did not adequately describe the resident's medical, physical, mental needs, and preferences, nor did it outline how the facility would assist in meeting these needs. Resident #83, a male with a history of significant medical conditions including limitations in range of motion (ROM) on both sides of the lower extremities and one side of the upper extremity, was observed without necessary positioning devices or interventions to assist with his condition. Despite being on hospice services, there was no documentation or care plan addressing his ROM limitations or the use of supportive devices like pillows. Interviews with facility staff, including the Director of Rehab, Registered Nurse (RN) Staff B, and the Director of Nursing (DON), revealed a lack of awareness and documentation regarding the resident's needs and the absence of a restorative program. The Care Plan Coordinator confirmed that there were no interventions documented for the resident's lower extremity limitations, and the resident's refusal of care was not properly documented. The deficiency was further highlighted by the absence of a care plan addressing the resident's ROM limitations, despite the resident's significant change in condition being noted in the Minimum Data Set (MDS) assessment.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. #83 care plan was updated to reflect resident current status. B. Education for F656 provided to RN staff B, care plan coordinator Staff L and Care plan coordinator RN staff H. C. Director of Rehab is no longer at the facility. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete Audit of resident with contractors and limited ROM was conducted and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. License staff was educated on the components of F656. B. Nursing management will review 24 hour report and follow up on any new limited ROM or contractors and update care plan as needed. C. All New residents will be reviewed and reassessed if needed and review by the IDT team the following business day for any limited ROM or contractors to ensure appropriate interventions are in place. D. Education on F656 will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Care Plans/Designee will audit new residents' charts and any change of condition charts to ensure that care plans are appropriate to reflect the status of the resident with emphasis on contractor or limited ROM weekly for four weeks then monthly for one quarter. The Director of Care Plans/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with NFPA 101 standards, as evidenced by a review of records and interviews. On February 11, 2025, it was found that the annual fire alarm report from November 4, 2023, indicated that 8 out of 12 duct detectors could not be located for testing. Additionally, the report noted that the batteries required replacement. Furthermore, the smoke detector sensitivity inspection report was outdated, with the last inspection dated February 19, 2021, and the duct detector air stream test was last conducted on September 6, 2023. The facility's administrator acknowledged these findings and mentioned that their vendor would need to provide updated testing. The failure to maintain the fire alarm system as per NFPA 101 standards could potentially delay alarm activation during hazardous conditions, although this risk is not explicitly stated in the report. The deficiency highlights lapses in the facility's adherence to required testing and maintenance schedules for critical safety equipment.
Plan Of Correction
K345 Fire Alarm System - Testing and Maintenance 1. The fire alarm inspection was conducted and is currently up to date. 2. Completed audit was conducted and any abnormal findings were corrected. 3. A. Vendor has the facility on schedule to do inspection based on regulatory requirements. B. Maintenance director educated on K345. 4. Maintenance Director will do monthly audits of Fire alarm testing and Maintenance to monthly QAPI. K345 Fire Alarm System Testing and Maintenance 1. The fire alarm inspection was conducted and is currently up to date. 2. Completed audit was conducted and any abnormal findings were corrected. 3. A. Vendor has the facility on schedule to do inspection based on regulatory requirements. B. Maintenance director educated on K345. 4. Maintenance Director will do monthly audits of Fire alarm testing and Maintenance to monthly QAPI.
Fire Drill Record Alterations
Penalty
Summary
The facility failed to conduct fire drills as required by NFPA 101, which mandates that fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. These drills are to be held at unexpected times under varying conditions, at least quarterly on each shift. During a review of the facility's fire drill records, it was found that the sign-in sheets for the drills did not have matching dates, and some dates were altered. Specifically, the fire drills dated 8/14/24 and 7/25/24 had matching sign-in sheets, but the dates were changed. Similarly, the drills on 11/29/24 and 10/31/24 had matching sign-in sheets, but the dates were removed from the sheets. The Maintenance Director, who had recently started working at the facility, stated that he did not conduct the drills prior to the survey. The Administrator, upon reviewing the drills, acknowledged the visible alterations in the records and indicated that further investigation would be conducted. This deficiency could result in staff not being prepared to address and respond to a fire emergency, thereby endangering the occupants of the building.
Plan Of Correction
K712 Fire Drills 1. Fire Drills are current and up to date. 2. Audit was completed on fire drills; any abnormal finding was noted. 3. A. Fire Drill will be conducted monthly. B. Staff educated on fire drills. 4. Administrator will audit monthly to ensure fire drills are completed, and findings will be brought to QA.
Failure to Conduct Timely Fire Door and Damper Inspections
Penalty
Summary
The facility failed to conduct timely inspections and testing of fire doors and fire and smoke dampers as required by NFPA 80 standards. During a records review, it was found that the last maintenance and testing reports for fire and smoke dampers were dated over four years ago, on 3/5/20, which exceeds the maximum interval of four years for testing these devices. Additionally, the inspection report for fire doors was dated 7/4/22, indicating a lapse in the annual inspection requirement. The Director of Maintenance acknowledged the backlog in maintenance tasks, attributing it to the previous maintenance director. This deficiency in maintenance practices could lead to the failure of fire and smoke dampers during fire conditions, potentially allowing the spread of fire, smoke, and gases throughout the building's smoke compartments. This oversight affects all smoke compartments within the facility, posing a risk to the safety of its occupants. The individuals responsible for performing these inspections and tests are required to have the necessary knowledge, training, or experience, and written records of these activities must be maintained and available for review.
Plan Of Correction
K761 Maintenance Inspection & Testing - Doors 1. Fire doors and fire and smoke dampers were inspected and current. 2. All fire doors and dampers were audited and inspected. 3. A. Cintas has been retained, and inspection has been placed on their schedule to maintain compliance with regulatory guidelines. B. Maintenance director and maintenance staff educated on K761. 4. Maintenance director will audit to ensure facility remains in compliance and report findings to QAPI. K761 Maintenance Inspection & Testing - Doors 1. Fire doors and fire and smoke dampers were inspected and current. 2. All fire doors and dampers were audited and inspected. 3. A. Cintas has been retained, and inspection has been placed on their schedule to maintain compliance with regulatory guidelines. B. Maintenance director and maintenance staff educated on K761. 4. Maintenance director will audit to ensure facility remains in compliance and report findings to QAPI.
Lack of Post-Disaster Analysis Documentation
Penalty
Summary
The facility failed to provide documentation of post-disaster analysis, including potential areas of improvement and revision of the Emergency Preparedness Program (EP). This deficiency was identified during a review of disaster drills conducted by the facility. Specifically, one of the required two drills did not include an After Action Report (AAR), which is essential for evaluating the facility's response to emergencies and identifying areas for improvement. During the review, it was noted that the absence of an AAR could leave the facility unprepared for unexpected situations that might arise during an actual emergency. The AAR is a critical component of the emergency preparedness process, as it allows the facility to document its response to drills and real events, analyze the effectiveness of its emergency plan, and make necessary revisions to address any shortcomings. The deficiency was confirmed through an interview with the Administrator, who acknowledged the omission and indicated that future drills would include an AAR. However, the lack of documentation for the drill in question highlights a gap in the facility's emergency preparedness efforts, which could potentially impact its ability to respond effectively to real emergencies.
Plan Of Correction
3/12/25 1. Drills were updated to meet the requirements of E039. 2. Audit of E tags was conducted, and any incorrect findings were corrected. 3. Education provided for E39. 4. Audit for compliance for E39 will be completed by administrator or designee monthly and report to QAPI for one quarter.
Failure to Test Electrical Equipment as per NFPA Standards
Penalty
Summary
The facility failed to test electrical equipment in accordance with NFPA 99 and NFPA 110 standards. During a review of the facility's maintenance and testing documents, it was found that there were no records of main and feeder circuit breaker inspections and exercising. The only available record was a thermal imaging report dated May 13, 2022. This lack of documentation was acknowledged by the Maintenance Director, who had recently started working at the facility and was unsure of the current status of the records. The deficiency could result in a loss of power to the facility, energized equipment fires, or fires resulting from devices failing to perform as designed. This poses a risk to the occupants of the building from electric shock hazards or the loss of power providing life support and life safety features of the facility. The report highlights the importance of exercising these breakers to ensure their reliability in the event of a fault or overload situation, as per NFPA 99 (2012 edition) and NFPA 110 (2010 edition).
Plan Of Correction
3/12/25 **Electrical Systems - Essential Electric System** 1. Main and feeder circuit breaker inspection and exercising was completed. 2. Audit was conducted to ensure all other inspections were completed; any abnormal findings were corrected. 3. A. The facility has placed in TELS system a schedule to do the inspection according to the regulatory guidelines to maintain compliance. B. Maintenance director and maintenance staff educated on K918. 4. Maintenance Director will do monthly audit to ensure facility maintain compliance with its inspection and report findings to QAPI.
Deficient Emergency Preparedness Communication Plan
Penalty
Summary
The facility failed to maintain an up-to-date communication plan as part of their Emergency Preparedness Program (EP). During a review conducted on February 11, 2025, it was found that the list of staff included individuals who no longer worked at the facility. This deficiency was identified through a record review and interview process, where the Administrator acknowledged that the plan had been reviewed through the Quality Assurance and Performance Improvement (QAPI) process but still required several updates, including current staffing information. The absence of an accurate communication plan, particularly in the context of an emergency, poses a risk to residents as it could lead to a lack of medical and support staffing during a transfer to other facilities. The deficiency highlights the facility's failure to ensure that the communication plan includes the necessary names and contact information of staff and residents' physicians, which is crucial for effective emergency response and resident safety.
Plan Of Correction
1. Name and contact information was updated to reflect current contacts and employees. 2. Audit of E tags was conducted, and any incorrect findings were corrected. 3. Education provided for E030. 4. Audit for compliance for E30 will be completed by administrator or designee monthly and reported to QAPI for one quarter.
Deficiency in Emergency Preparedness Communication Plan
Penalty
Summary
The facility failed to provide a method for sharing occupancy information and needs as part of their Emergency Preparedness Program (EP). This deficiency was identified during a record review and interview, where it was found that the facility's EP did not include a clear method for communicating occupancy needs to the authority having jurisdiction. This lack of communication could potentially leave receiving facilities and caregivers without the necessary information for accommodating transferred residents. During the review, it was noted that the facility's EP referenced the Emergency Status System (ESS) and included a link to the ESS website. However, the Administrator acknowledged that they would use the online resource 'HFRS' and update the EP to reflect this new website. This indicates that the current EP did not adequately address the requirement for sharing occupancy information, which is crucial for maintaining continuity of care during transfers or intakes of residents.
Plan Of Correction
3/12/25 1. The link was updated to reflect HFRS instead of the old site ESS. 2. Audit of E tags was conducted, and any incorrect findings were corrected. 3. Education provided for E033. 4. Audit for compliance for E33 will be completed by administrator or designee monthly and report to QAPI for one quarter.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and sanitary environment for residents, as evidenced by multiple observations and interviews. During an initial tour, surveyors observed a large live insect behind an oxygen concentrator, a wash basin stored on the floor of a shared bathroom, exposed wires of a call light, missing closet drawers, damaged vinyl flooring, and missing baseboards exposing cracked drywall. Additionally, the ice machine in the main dining room was found to have a white substance and dust, indicating it was not being cleaned as per facility policy. Staff interviews confirmed the presence of roaches and bugs, with multiple staff members stating that while they reported these issues, the extermination efforts were ineffective, and maintenance requests were often delayed or ignored for weeks. Residents and their families also reported frequent sightings of roaches and expressed concerns about the facility's cleanliness and maintenance. The Administrator admitted to not touring the facility to observe these concerns and acknowledged a lack of oversight in ensuring that maintenance and cleaning tasks were completed. The Regional Director of Maintenance was unaware of the ongoing issues and declined to conduct a joint tour of the facility. The Certified Dietary Manager confirmed that there was no documentation to verify that the ice machines and coolers were being cleaned and sanitized as required. Housekeeping staff also reported seeing roaches daily and indicated that they only cleaned the outside of the ice coolers, not the inside. These observations and interviews highlight significant deficiencies in the facility's ability to maintain a safe, clean, and comfortable environment for its residents.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide necessary care and services to maintain hygiene for three residents who required assistance with activities of daily living (ADLs). Resident #24, who had diagnoses including depression, chronic obstructive pulmonary disease, and type 2 diabetes mellitus, did not receive scheduled showers on multiple occasions in March and April 2024. The CNA documentation showed inconsistencies and lack of proper documentation for the scheduled showers, with the resident receiving only one shower in March and none in April. The resident's representative confirmed the lack of scheduled showers during a telephone interview. Resident #999, who had diagnoses including chronic kidney disease, metastatic breast cancer, and type 2 diabetes mellitus, did not receive any scheduled showers during her stay from October 2023 to November 2023. The CNA documentation indicated that the resident received partial bed baths instead of scheduled showers, with no documentation of shower refusals. Additionally, Resident #750, who required substantial to maximum assistance with personal care, did not receive any scheduled showers from the time of admission on April 29, 2024, to May 7, 2024. The CNA staff and the Director of Nursing confirmed the lack of a policy on ADLs or bathing of residents and the absence of a clear responsibility for ensuring showers were completed as assigned.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program and a sanitary environment free from pests for residents residing in the skilled nursing facility. On multiple occasions, residents and staff reported the presence of large roaches and other insects in resident rooms and common areas. Observations included a live brown insect in a resident's room and a dead bug on a conference room table. Residents expressed concerns about bugs crawling on walls and even on them at night, while staff confirmed the frequent presence of pests and their attempts to manage the situation by stepping on the bugs and logging sightings for the exterminator. However, the pest control measures in place were ineffective, as evidenced by the recurring pest sightings and the exterminator's admission that the previous pest control reports indicated no pest activity despite the ongoing issues reported by residents and staff. Interviews with the pest control exterminator revealed that this was his first visit to the facility, and he had not received any prior reports of pest activity from the previous exterminator. The exterminator noted that the large roaches likely originated from old sewer lines and outside mulch areas. Despite regular spraying, the pest control measures were insufficient, particularly after rain, leading to the persistent presence of pests. The facility's pest log was also found to be inadequate, with no documented pest activity on several dates, contradicting the numerous reports and observations of pests by residents and staff.
Failure to Address Grievances Related to Maintenance Issues
Penalty
Summary
The facility failed to address grievances related to broken furniture and a frayed call light for a resident. The resident's representative reported these issues to the facility Administrator, and work orders were filed, but the repairs were not completed. The resident's closet drawer was missing, and the call light had exposed wiring, which was confirmed through photographic evidence and observations by the surveyor. The issues had been reported multiple times over several months, but no corrective action was taken. The Regional Director of Maintenance was unaware of the maintenance concerns and confirmed the deficiencies during a tour of the resident's room. The Administrator admitted that the Maintenance Director, who had recently left the facility, was responsible for repairs but did not ensure the completion of the tasks. The Administrator acknowledged that he did not follow up to verify that the repairs were made, assuming they were taken care of by the Maintenance Director.
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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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