Shores Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Port Saint Joe, Florida.
- Location
- 220 Ninth Street, Port Saint Joe, Florida 32456
- CMS Provider Number
- 105435
- Inspections on file
- 27
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Shores Nursing And Rehab Center during CMS and state inspections, most recent first.
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.
A resident was repeatedly observed in heavily soiled clothing and on soiled bedding with a strong urine odor over multiple days, despite stating they had requested assistance with changing and hygiene. The resident, who had moderate cognitive impairment and occasional incontinence but required staff help with bathing, grooming, toileting, and incontinence care, was left in the same dirty clothes and linens, and at one point reported having to change themselves due to lack of staff response. The care plan did not specify the level of ADL assistance needed, laundry was left in bags for nursing staff to distribute rather than returned to the room, and the DON reported expectations for 2-hourly rounding and ADL care but confirmed there were no written ADL or resident care policies.
Surveyors found that the Memory Care unit was not kept clean or comfortable, with food debris and sticky floors throughout, and a resident's room containing a dirty mattress and stained bedsheet. A PCA was performing housekeeping duties due to staff absences, and both the DON and an RN acknowledged the inadequate cleanliness.
Multiple residents voiced ongoing concerns about the repetitive menu and limited food options, filing a formal grievance through the Resident Council. Despite documentation of complaints and an investigation that involved sending evidence to corporate, the grievance remained unresolved, and staff interviews revealed a lack of awareness and follow-up regarding the issue, contrary to the facility's grievance policy.
A resident's room was found to have damaged baseboards held together with tape and a bed frame with extensive rust, while maintenance staff failed to identify or address these issues during routine checks. The maintenance log only reflected unrelated minor repairs, and no new beds had been ordered despite claims to the contrary.
Surveyors found that the facility did not develop or implement complete, person-centered care plans for several residents with complex medical and behavioral needs. For example, a resident with dementia and behavioral complaints had no care plan interventions addressing these issues, and other residents lacked care plans for conditions such as limited range of motion, safe smoking with oxygen, and disease-specific needs. The DON confirmed that care plans were missing or incomplete for multiple residents.
A resident who required moderate to maximum assistance with personal hygiene, dressing, grooming, and oral care was repeatedly observed with unkempt hair, stained clothing, visible food particles, and poor oral hygiene. Despite a care plan outlining the need for staff assistance with these activities, the resident was not provided adequate support, resulting in ongoing unmet needs.
A resident with a left hand contracture and history of CVA did not receive appropriate range of motion care, as repeated observations showed no splints or devices were applied and no restorative program was in place. Staff interviews confirmed that restorative care was inconsistent due to staffing issues, and record review showed the resident had significant functional limitations without a maintenance program.
A resident with a newly placed AV fistula for dialysis did not receive consistent monitoring of the fistula's bruit and thrill by nursing staff. Despite discharge instructions to check the site daily, documentation showed assessments occurred only on three occasions, and there were no physician's orders for monitoring until nearly a month after placement. The DON confirmed the lack of orders and ongoing assessment prior to that time.
A resident with hepatic encephalopathy and liver cirrhosis did not receive prescribed rifaximin on multiple days because the medication was not available from the pharmacy. After missing several doses, the resident experienced increased confusion, tremors, and a decline in self-care, resulting in transfer to a hospital for altered mental status. Facility records and staff interviews confirmed the medication was unavailable for several days prior to the resident's transfer.
The facility did not provide documentation that several residents received education or were offered the pneumococcal vaccine, as required by policy. Review of medical records and staff interviews confirmed that forms indicating education, consent, or declination were missing for these residents.
The facility did not provide documentation showing that several residents received education about and were offered the COVID-19 vaccine, as required by policy. Interviews with nursing leadership confirmed that such documentation should be present in the medical record, but it could not be located for the affected residents.
Two resident rooms were found to have privacy curtains that were too short in width to ensure full visual privacy between beds, as confirmed by facility staff during an observation. The Administrator acknowledged the expectation for each room to provide complete visual privacy.
The facility failed to conduct annual performance reviews and training for a CNA, identified as Staff Member D, who was unable to recall her last training on resident rights and working with cognitively impaired residents. The DON confirmed that evaluations and training were only completed recently, with no prior documentation available.
The facility failed to promote resident dignity and quality of life by not allowing residents to wear personal clothing, not providing enough clean clothes, and restricting movement at night. A resident was found unclothed and distressed over lack of assistance, while others reported issues with soiled linens and rude night staff. The DON acknowledged these concerns.
A linen shortage in the facility affected resident care, with several residents lacking clean clothing and bed linens. Staff reported difficulties in obtaining necessary linens, and observations confirmed poorly stocked linen rooms. The Maintenance Director acknowledged the issue, citing delays in linen orders due to administrative approval processes.
The facility failed to resolve grievances promptly for several residents, as required by their policy. Grievances included inappropriate staff behavior, lack of assistance, and issues with medication and personal care. These grievances were not documented or investigated, and the Social Services Director responsible was terminated for not performing these duties.
The facility failed to provide timely assistance with daily living activities, including hygiene and nail care, due to staffing shortages. Residents were found in soiled conditions, with some reporting infrequent baths and falls due to lack of assistance. Staff interviews confirmed inadequate staffing, particularly on evening and night shifts, impacting care quality.
The facility failed to provide sufficient staffing to meet residents' basic needs, resulting in inadequate assistance with daily living activities such as bathing, dressing, and oral hygiene. Residents reported long wait times for help, missed showers, and unsanitary conditions. Staffing shortages, particularly during evening and night shifts, led to unmet care needs and compromised hygiene, as corroborated by staff interviews.
A facility failed to develop a comprehensive care plan for a resident requiring wound care. Despite having a physician's order for wound treatment, the resident's care plan lacked goals and interventions for wound care. A review confirmed the oversight, which was against the facility's policy requiring comprehensive care plans with measurable objectives.
A facility failed to obtain lab results for a resident after a physician ordered tests for CBC, BMP, and Hemoglobin A1c. The Treatment Administration Record indicated the blood sample was collected, but no results were found in the medical records. The DON requested the results, but they were not provided, and an RN confirmed the absence of lab results despite the completed documentation.
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.
Failure to Provide Timely Personal Care and Hygiene Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate and appropriate health care and personal care services to maintain grooming and hygiene for one resident. Surveyors observed the resident on multiple occasions in visibly soiled clothing with a strong odor of urine. On one afternoon, the resident was seen standing in his doorway with navy pants wet from the seat down to both calves, reporting he had been waiting for staff to change his clothes. Later that same day, he was still in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, the resident was again observed wearing the same soiled clothes, smelling of urine, with his shirt soiled with food and a dark liquid. His room had a strong urine odor, and his bed was soiled with urine. Only two pairs of pants were seen in the room, and no other clothing was observed. On a subsequent observation, the resident was seated on the edge of his bed wearing khaki pants and no shirt, with yellow-soiled sheets beneath him and his previously soiled red shirt and navy pants on the floor at the end of the bed. The resident stated he had requested assistance with changing clothes but staff had not come, so he changed himself. Record review showed a history of multiple medical conditions and a recent Quarterly MDS indicating a moderate level of cognitive impairment, with the resident moderately independent for toileting, personal hygiene, and other ADLs, and occasionally incontinent. The resident’s care plan did not specify the level of staff assistance required for personal care and ADLs. An LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and incontinence care, did not refuse care, and appropriately requested help. The LPN also explained that laundry staff left clean, labeled clothing in bags in the linen room for nursing staff to distribute. The DON stated that staff were expected to perform rounds every two hours and as needed, keep residents clean and dry, and provide all needed ADL care, but acknowledged the facility had no written ADL, resident care, or quality of care policies.
Failure to Maintain Clean and Homelike Environment in Memory Care Unit
Penalty
Summary
Surveyors observed that the Memory Care unit (400 Hall) was not maintained in a clean, comfortable, and homelike condition. During a facility tour, floors throughout the unit, including the dining area and all resident rooms, were found to have food debris and were sticky. One resident room had a mattress on the floor with fall mats, and both the mattress and mats were dirty, with the bedsheet visibly stained. Staff interviews revealed that a Personal Care Assistant was performing housekeeping duties due to the absence of regular housekeeping and maintenance staff, who had called out sick. The Director of Nursing confirmed the staff shortage, and a Registered Nurse acknowledged that the cleanliness of the unit was inadequate, specifically noting the state of the floors and rooms. These observations and staff statements directly indicated a failure to provide a safe, clean, and homelike environment for residents in the Memory Care unit.
Failure to Address Resident Council Grievance Regarding Food Quality and Variety
Penalty
Summary
The facility failed to act upon a grievance filed by the Resident Council regarding the variety and quality of food served. During a meeting with Resident Council members, multiple residents expressed ongoing dissatisfaction with the food, citing repetitive menus, limited alternate meal options, and the discontinuation of certain preferred items such as fried chicken. Residents reported that their complaints about food quality and variety had been raised multiple times, including in council meeting minutes and a formal grievance, but the issues persisted. The grievance investigation noted that pictures of portion sizes and repetitive menu items were sent to corporate, and a plan was made to work with the contracted food service company to improve offerings, but the grievance remained unresolved and residents continued to express dissatisfaction. Interviews with facility staff revealed a lack of awareness and follow-through regarding the grievance. The Dietary Manager was unaware of the specific grievance and stated that menu changes were routine and not in response to resident concerns. The Social Services Director confirmed ongoing complaints and stated that the grievance was reported to corporate, but could not provide evidence of any measures taken to resolve the issue or follow-up with residents. The facility's grievance policy requires prompt efforts to resolve complaints and inform residents of progress, but there was no documentation showing that these steps were taken in response to the Resident Council's food-related grievance.
Failure to Maintain Safe and Sanitary Resident Equipment
Penalty
Summary
The facility failed to maintain resident equipment in a safe and sanitary manner in one of the resident rooms. During observation, the baseboards in the room were found to be damaged, cracked, and held together with blue painter's tape, while the bed frame of one resident was extensively rusted, covering more than half its length. Maintenance Employee A reported conducting daily rounds to check exit doors and hallways and reviewing the maintenance log at each nurse's station, but was unaware of the extent of the rust on the bed and the damaged baseboards. The maintenance log only noted a need for replacement light bulbs in the room, and although Employee A entered the room to replace the bulbs, he did not notice or document the other issues. The Administrator initially stated that beds were on order but later confirmed that no beds had actually been ordered.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that addressed all identified needs for multiple residents. For one resident with dementia, observations and interviews revealed complaints of not being treated with dignity and respect, and reports from the resident's daughter indicated that staff were sometimes rough. Despite these behavioral concerns and allegations, there were no care plan interventions in place to address the resident's behaviors or false allegations, even though the care plan included other risks such as falls and communication deficits. The Director of Nursing acknowledged that these behaviors should have been care planned but were not. For another resident with multiple diagnoses including COPD, dementia, schizophrenia, CVA, diabetes, epilepsy, and heart failure, a plan of care was initiated to review functional abilities, but no interventions were included. Additionally, there was no care plan in place for limited range of motion until after an interview with the DON. The facility only had a partial restorative program in place, limited to dining activities. Other residents with complex medical histories, such as those on hospice, with indwelling catheters, or at risk for elopement, also lacked care plans addressing key aspects of their care, such as safe smoking practices, oxygen therapy, dementia, communication deficits, and disease-specific interventions. Record reviews and staff interviews confirmed that care plans were either missing, incomplete, or not updated to reflect the residents' current needs and conditions. The DON acknowledged that the care plans did not directly address the residents' care needs, resulting in a failure to provide a comprehensive care plan process for six out of twenty-one residents reviewed.
Failure to Provide Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to provide adequate care and assistance with activities of daily living for a resident who was unable to perform these tasks independently. Multiple observations over several days revealed the resident in various states of poor hygiene and unkempt appearance, including tangled and messy hair, food particles in her lap and on her clothing, and stained, unclean shirts. The resident was also repeatedly observed with a thick yellowish substance around her teeth and gum line, indicating a lack of oral care. At times, her clothing was improperly positioned, such as a shirt pulled up to expose her abdomen, and her incontinent brief was visible above her pants. The resident was often seen slumped in her wheelchair or lying in bed, with little evidence of assistance provided to maintain her cleanliness or dignity. Record review indicated that the resident required moderate to maximum assistance with personal hygiene, showers, incontinent care, dressing, toileting, and transfers, as documented in her MDS assessment and care plan. The care plan specified that staff were to provide assistance with hygiene, mobility, dressing, grooming, oral care, and toileting needs. Despite these documented needs and interventions, the resident was consistently observed in a state that demonstrated a lack of appropriate care and assistance with activities of daily living.
Failure to Provide Range of Motion Care for Resident with Contracture
Penalty
Summary
The facility failed to provide appropriate care and services to maintain or improve range of motion (ROM) for a resident with a left hand contracture. Multiple observations over several days showed that the resident consistently did not have any splints or devices applied to her left hand to address the contracture, despite a care plan indicating a history of CVA and left side hemiparesis with a left hand contracture. Staff interviews revealed that the facility had not maintained a restorative program for some time, and the designated restorative aide was also required to perform regular CNA duties, limiting her ability to provide consistent restorative care, including ROM exercises and application of splints or devices. Record review indicated that the resident had significant functional limitations and impairments to both upper and lower extremities, as documented in the MDS and therapy screenings. Although therapy discharge summaries recommended 24-hour care, there were no restorative or functional maintenance programs in place for the resident at the time of the deficiency. The lack of consistent application of splints or devices and absence of a restorative program contributed to the facility's failure to provide necessary care and services to address the resident's contracture and limited ROM.
Failure to Monitor AV Fistula for Dialysis Resident
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a newly placed arteriovenous (AV) fistula required for dialysis. The resident reported that nursing staff did not touch, palpate, or assess the fistula. Medical record review showed the AV fistula was placed on 4/10/25, but there were no physician's orders to check the bruit and thrill until 5/7/25. Hospital discharge instructions specified that the fistula site should be checked daily to ensure the thrill remained the same. Documentation revealed that the thrill was only assessed by nursing staff on three occasions: 4/12/25, 4/13/25, and 4/20/25. The DON confirmed that there were no orders to monitor the bruit and thrill prior to 5/7/25, despite the need for ongoing assessment since the fistula was placed.
Failure to Provide Prescribed Medication for Hepatic Encephalopathy
Penalty
Summary
A deficiency occurred when a resident with hepatic encephalopathy and liver cirrhosis did not receive their prescribed rifaximin 550 mg twice daily on multiple occasions due to the medication not being available from the pharmacy. The medication administration record and progress notes documented missed doses on several specific dates. The package insert for rifaximin indicates its use in reducing the risk of overt hepatic encephalopathy recurrence, and the resident was admitted with this diagnosis. On one of the days following missed doses, the resident experienced a change in condition, including increased tremors, confusion, and a decline in self-care, which led to a transfer to an acute care hospital for altered mental status. Hospital records confirmed that the facility had been out of rifaximin for several days prior to the transfer. During an interview, the DON acknowledged the resident's increased confusion and emotional upset when not receiving liver medications and confirmed the pharmacy's practice of sending only a five-day supply due to the medication's high cost.
Failure to Document Pneumococcal Vaccine Education and Consent
Penalty
Summary
The facility failed to provide documentation that four out of six residents reviewed had received education and were offered the pneumococcal immunization. Upon review of the medical records for these residents, there was no evidence of education, consent, or declination regarding the pneumococcal vaccine. Both paper and electronic records were checked, and interviews with the ADON and DON confirmed that such documentation should be present if a resident declines the vaccine. However, the required forms could not be located for the affected residents. According to the facility's policy, residents are to be assessed for pneumococcal vaccine eligibility upon or prior to admission, and the vaccine should be offered within 30 days unless contraindicated or previously administered. The policy also requires documentation of education and any refusal in the resident's medical record. The absence of this documentation for the four residents reviewed constitutes a failure to follow established procedures for immunization education and consent.
Failure to Document COVID-19 Vaccine Education and Offer
Penalty
Summary
The facility failed to provide documentation that five out of six residents reviewed had received education and were offered the COVID-19 immunization, as required by facility policy. Upon review of both paper and electronic medical records, there was missing documentation regarding education and consent or declination of the COVID-19 vaccine for these residents. Interviews with the ADON and DON confirmed that education and the offer of immunization should occur on admission, and that a signed declination form should be present if a resident refuses the vaccine. Despite attempts to locate the required forms, the facility was unable to provide documentation for the affected residents. The facility's admission packet specifies that all residents are to be educated and offered the COVID-19 vaccine, with a signature required to indicate acceptance or declination.
Insufficient Privacy Curtains Compromise Resident Visual Privacy
Penalty
Summary
During an observation of two resident rooms, it was found that the privacy curtains between the occupied beds were insufficient in width to provide full visual privacy. In one room, the curtain was measured and found to be approximately two feet too short, while in another room, the curtain was about eighteen inches too short. These findings were confirmed by both the Maintenance Director and the Administrator during the walkthrough. The Administrator acknowledged that each room is expected to be equipped to provide full visual privacy to each resident. Photographic evidence was obtained to document the deficiency.
Failure to Conduct Timely Performance Reviews and Training
Penalty
Summary
The facility failed to ensure that employee performance reviews were completed every 12 months for one of the six sampled Certified Nursing Assistant (CNA) staff members, identified as Staff Member D. During an interview, Staff Member D was unable to recall when her last training on resident rights, abuse prevention, and working with cognitively impaired residents with difficult behaviors occurred. A review of her employee file revealed that she was hired on 10/20/22, but there were no records of any performance evaluations or training in responding to cognitively impaired residents with difficult behaviors prior to 10/30/24. The Director of Nursing (DON) confirmed that the performance evaluation and training for Staff Member D were only completed on 10/30/24, the day before the interview. The DON was unable to provide any documentation of previous training or evaluations for Staff Member D before this date. This indicates a lapse in the facility's adherence to the requirement for annual performance evaluations and training for staff members, particularly in handling cognitively impaired residents with difficult behaviors.
Failure to Promote Resident Dignity and Quality of Life
Penalty
Summary
The facility failed to uphold the dignity and quality of life for several residents by not allowing them to wear their personal clothing, not providing enough clean clothes, and restricting movement at night. Specifically, four residents were not allowed to wear their own clothes, and two residents did not receive enough clean clothes. One resident was restricted from leaving his room at night, which he expressed was due to staff citing it as a fire hazard. Additionally, there were issues with the availability of incontinence care supplies, leading to a resident wearing the same pull-up since the previous evening. Observations revealed that one resident was found unclothed in her bed with a strong smell of urine in the room, and she expressed distress over not receiving assistance for bathing. Another resident was using soiled bed linens and had unsuccessfully requested clean sheets. Multiple residents were observed wearing gowns despite preferring their own clothes, and one resident reported that night shift staff were rude and unaccommodating. The Director of Nursing acknowledged the concerns and mentioned efforts to provide clothing to residents in need.
Linen Shortage Affects Resident Care
Penalty
Summary
The facility failed to provide adequate supplies of clean laundry in four out of five linen storage areas, affecting eight of the 32 residents sampled. This deficiency was observed through resident and staff interviews, as well as direct observations by the surveyor. Residents reported issues such as wearing soiled or inappropriate clothing, lack of bed linens, and prolonged use of the same clothing without being washed. For instance, one resident was found wearing a patient gown and expressed a preference for regular clothes, while another resident had been using the same sheets for several days without them being changed. Staff interviews revealed that the facility often experiences shortages in linen supplies, with CNAs describing the situation as "horrible" and noting that linen rooms are poorly stocked. The lack of fitted sheets and other essential linens was a recurring issue, with staff reporting that they sometimes have to wait until the end of the day shift to obtain necessary items. The surveyor's tour of the laundry rooms confirmed these shortages, with many shelves completely empty or minimally stocked with essential items like sheets, pillowcases, and gowns. The Maintenance Director, who oversees laundry services, acknowledged the shortage of linens and indicated that there was a stock of linens in plastic bags designated as emergency supplies. However, these were not being circulated for regular use. The director mentioned that he had ordered more linens, but the order was pending approval from the administrator, who was currently on leave. This delay in processing orders further contributed to the deficiency in providing a safe, clean, and comfortable environment for the residents.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure the prompt resolution of grievances for several residents, as required by their grievance policy. From May to July 2024, seven out of ten grievances sampled were not properly documented or investigated. Specific grievances included a resident reporting a night nurse's inappropriate behavior, another resident complaining about staff refusing to heat water, and a resident lacking clothes and being unable to eat in the dining hall. Additionally, a family member reported issues with medication administration and incontinence care for two residents. None of these grievances had documented investigations or resolutions. Resident #16 reported a grievance about neglectful behavior by a CNA, which was not documented or investigated. The resident provided text messages with the DON as evidence of the grievance. The DON acknowledged awareness of the grievance but stated that the grievance was never filed by the weekend supervisor. The facility's grievance policy requires prompt resolution and documentation of grievances, which was not adhered to in these cases. The Social Services Director responsible for handling grievances was terminated for failing to perform these duties.
Inadequate Resident Care Due to Staffing Shortages
Penalty
Summary
The facility failed to provide timely assistance to residents in performing activities of daily living, including oral care, nail care, podiatry care, and general hygiene. Observations and interviews revealed that multiple residents were left in soiled conditions, with strong odors of urine present in their rooms, indicating a lack of adequate incontinence care. Residents reported not receiving regular baths or showers, with some unable to recall their last bath. Additionally, residents expressed frustration over the lack of assistance with dressing, transfers, and other personal hygiene tasks. Resident #6 was found unclothed in bed with long toenails and a strong smell of urine in the room. She expressed distress over not receiving help with bathing and nail care. Resident #1 was observed with dry, cracked lips, long fingernails with debris, and long toenails, indicating neglect in oral and nail care. He reported not being assisted out of bed frequently and had only received oral hygiene assistance on a few occasions over several weeks. Other residents, such as Resident #8, reported falls and a lack of assistance during the night, leading to increased pain and difficulty in performing daily tasks. Staff interviews confirmed that the facility was experiencing staffing shortages, particularly on evening and night shifts, which impacted the ability to provide adequate care. Certified Nursing Assistants (CNAs) and Patient Care Assistants (PCAs) reported being overwhelmed with the number of residents they were responsible for, leading to missed care tasks such as turning residents, providing showers, and changing linens. The facility's reliance on PCAs, who are not yet certified, further exacerbated the issue, as they were unable to perform all necessary care tasks independently.
Inadequate Staffing Leads to Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient staffing to meet the basic needs of residents, as evidenced by observations, resident interviews, staff interviews, and record reviews. Residents reported inadequate assistance with daily living activities, such as bathing, dressing, and oral hygiene. Many residents were found in unsanitary conditions, with long nails, soiled linens, and strong odors of urine in their rooms. The lack of staff resulted in residents not receiving timely assistance, leading to unmet care needs and compromised hygiene. Several residents expressed dissatisfaction with the care provided, citing long wait times for assistance, missed showers, and infrequent checks by staff. Some residents reported incidents of neglect, such as being left in soiled briefs for extended periods and not receiving help with transfers or mobility. The facility's staffing shortages were particularly pronounced during evening and night shifts, with insufficient numbers of CNAs and an over-reliance on less experienced PCAs, who were unable to perform all necessary care tasks independently. Staff interviews corroborated the residents' accounts, highlighting the challenges faced due to inadequate staffing levels. CNAs and nurses reported being overwhelmed by the high acuity of residents and the demands of enhanced supervision for certain individuals. The facility's inability to maintain adequate staffing levels resulted in residents not being repositioned, bathed, or provided with necessary care in a timely manner, contributing to the overall deficiency in meeting residents' care needs.
Failure to Develop Comprehensive Wound Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who required wound care. The resident, who had been admitted with multiple diagnoses including type 2 diabetes mellitus with diabetic neuropathy, morbid obesity, hypertension, and chronic kidney disease, had a physician's order for wound care on the right scapula. This order, dated 5/30/24, specified cleansing the open area with wound cleanser and applying Duoderm every three nights and as needed. However, a review of the resident's most recent care plan, dated 6/6/24, revealed that it did not include any goals or interventions related to wound care, despite the resident having wounds prior to that date. An interview with a Registered Nurse and the facility's MDS coordinator confirmed that the resident should have been care planned for wounds during the most recent review. The facility's policy on comprehensive care plans, dated 9/1/2022, requires that each resident's care plan includes measurable objectives and timetables to meet their medical, nursing, mental, and psychological needs, and identifies the professional services responsible for each element of care. This policy was not adhered to in the case of the resident in question.
Failure to Obtain Laboratory Results for a Resident
Penalty
Summary
The facility failed to obtain laboratory results for a resident who was sampled for blood testing. A physician ordered laboratory tests for a Complete Blood Count (CBC), Basic Metabolic Panel (BMP), and Hemoglobin A1c on 7/22/24. The Treatment Administration Record (TAR) indicated that the blood sample collection was completed on the same date. However, upon review of the resident's medical records, no laboratory results were found on file. The Director of Nursing (DON) requested the results, but they were not provided. A Registered Nurse (RN) confirmed the absence of lab results despite the physician's order and the documentation indicating the collection was completed.
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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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