South Heritage Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Petersburg, Florida.
- Location
- 718 Lakeview Ave S, Saint Petersburg, Florida 33705
- CMS Provider Number
- 105117
- Inspections on file
- 18
- Latest survey
- April 25, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at South Heritage Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of chronic pancreatitis, Whipple procedure, splenectomy, prior Serratia bacteremia, and a recently removed surgical drain developed progressively worsening abdominal pain, distention, fevers, chills, and inability to tolerate PO intake after returning to the facility. The RN/Unit Manager reported that staff noted pain after drain removal, applied a dressing that later came off, and treated the resident with pain and nausea medications while following a practice of assessing changes in condition and reviewing VS to see if issues could be managed in-house. The resident ultimately called 911 independently to go to the hospital, rather than staff initiating the transfer, and the RN/Unit Manager stated she did not know what happened or the resident’s condition on hospital admission, reflecting the events leading to the cited resident rights deficiency.
A resident with complex pancreatic disease and recent abdominal surgery developed significant pain, bloating, vomiting, and later diarrhea, repeatedly requesting to go to the hospital while family also urged staff to send her out. Nursing notes show calls and pages to the MD, changes in pain medication, and an order for milk of magnesia, but no documented physician response to a family request for IV fluids and no documented follow-up after the resident insisted on hospital transfer. The resident ultimately called 911 herself, and paramedics transported her to the hospital, where she was admitted with sepsis and suspected pseudocyst. CNAs recalled the resident frequently vomiting, and the DON confirmed that staff should have assessed, documented vitals and monitoring, notified the physician, and assisted the resident in exercising her right to seek outside medical care, consistent with the facility’s resident rights policy.
A dependent resident with quadriplegia and significant ADL self-care deficits had fingernails observed to be approximately one to one and a half inches long after repeatedly requesting nail trimming from the assigned CNA over several days without the care being provided. The resident and a family member reported that the nails were last cut by family about six weeks earlier. Review of documentation over the prior month showed entries of "No Nail Care" with one documented refusal and no evidence of nail care being performed, despite facility expectations that CNAs or nurses provide nail care on weekends or PRN and when requested. The DON and an RN/UM acknowledged nail care as part of hygiene and infection control but were unclear on where nail care completion or refusals were to be documented, and the facility lacked a specific ADL or nail care policy.
A resident with quadriplegia and muscle wasting had a physician order for a house diet with restrictions and an additional order allowing double portions for all meals, six times a day, and the care plan and nutrition evaluation documented the resident’s request for large entrée portions. Surveyors observed a lunch meal where the tray ticket did not indicate large or double portions, and the Food Service Manager confirmed that only breakfast trays reflected large portions, while lunch and dinner tickets did not. The FSM stated that diet orders flow from the EMR to the meal tracker system and that he could not change them, and he did not see the double-portion order because it had been entered under an “other” category instead of dietary. The DON confirmed that diet orders should be entered correctly under dietary, documented on a dietary slip, and handed off to dietary staff, and acknowledged that the double-portion order had been miscategorized and not properly communicated.
Surveyors found that the facility failed to provide adequate nail care, implement diet-related physician orders, and support a resident’s right to seek outside medical care. One resident with quadriplegia had fingernails grown to about one to one and a half inches despite repeatedly requesting trimming over several days; documentation showed no nail care for about a month, and staff could not clearly identify where such care was recorded. The same resident had an order for double portions at all meals, but only breakfast trays reflected large portions because the order was mis-entered under a non-dietary category and never properly communicated to dietary staff. In a separate case, a post-surgical resident with pancreatic disease developed abdominal pain, vomiting, and diarrhea and repeatedly requested to go to the ER; the family reported begging staff to send her out, while notes showed calls to the MD, medication changes, and a delay until the resident ultimately called 911 herself, after which hospital evaluation revealed postoperative fluid collections and systemic symptoms.
Surveyors found that two residents experienced multiple medication errors, including late administration, incorrect medication, improper insulin administration due to lack of pen needles, and failures in hand hygiene and documentation. LPNs did not follow manufacturer or facility protocols, and the DON was unaware of ongoing supply issues, resulting in a medication error rate of 68.18%.
Surveyors found that staff failed to follow infection control protocols, including leaving an insulin syringe unsheathed on multiple surfaces, not using a barrier on an over bed table, neglecting hand hygiene and glove use during eye drop administration, and having direct care nurses with excessively long fingernails. These actions were confirmed by staff and contradicted both facility policy and CDC guidance.
Surveyors found unsanitary conditions in the main shower room and two shared bathrooms, including hair, debris, and bio-growth on floors and equipment. Housekeeping staff reported inconsistent cleaning routines and unclear responsibilities for shower maintenance, resulting in a failure to meet facility policy for a clean and comfortable environment.
A resident with multiple health issues experienced an unwitnessed fall and was assisted back to bed by staff without a documented assessment or evaluation for injuries. Despite ongoing complaints of pain reported by the roommate, staff did not document the incident or order an X-ray until two days later, which revealed a hip fracture requiring surgery. Facility protocols for post-fall assessment and notification were not followed, resulting in delayed identification and treatment of the injury.
A resident who was dependent for transfers and required a mechanical lift with two staff assistance was transferred by a single CNA, contrary to the care plan and facility policy. During the transfer, the resident fell and sustained a significant femur fracture, with investigation confirming that the required two-person assistance was not provided.
The facility did not ensure an RN was on duty for eight consecutive hours each day as required, with staff schedules showing only LPNs present and the RN's name crossed out. The DON confirmed gaps in RN coverage due to call-offs and lack of real-time monitoring, despite facility policy requiring daily staffing evaluation.
A resident with significant mobility impairments suffered a severe leg fracture after being transferred by a single CNA without the required use of a mechanical lift and two-person assistance. There were also multiple discrepancies in the documentation of controlled medication administration, and the resident's emergency contact was not notified following a hospital transfer after the fall, contrary to facility policy.
A resident with multiple medical conditions experienced a fall and was transferred to the hospital, but the facility did not notify the designated emergency contact or document such notification. The family only became aware of the hospitalization after being informed by the resident herself, and facility records lacked evidence of required communication with the family, despite policy mandating notification and documentation.
A resident who was cognitively intact and dependent on staff for transfers after recent leg surgery received oxycodone for pain, but staff failed to accurately document administration of the medication. Multiple doses were recorded on the controlled drug inventory sheets but not on the MAR, and there were inconsistencies in administration times between records. The DON confirmed these discrepancies, which were not in line with facility policy requiring immediate and accurate documentation of controlled substances.
The facility's dishwashing machine was found to have an excessively high concentration of chemical chlorine sanitizer, exceeding the required range of 50-100 ppm. Despite this, the machine continued to be used for meal services without corrective action. The issue was previously cited during a health inspection, but no in-services or education were provided to staff, and the Dietary Manager lacked access to the machine's operations manual or policy.
The facility failed to maintain a sanitary and safe environment, with observations of unsanitary conditions and broken fixtures across two units. Issues included brown substances around toilets, bio-growth on shower chairs, and malfunctioning fixtures. Maintenance and housekeeping staff were unaware of these problems, indicating a breakdown in communication and oversight.
Two residents experienced unresolved grievances related to their wheelchairs. One resident's wheelchair was lost during a hurricane evacuation and was not replaced with a suitable one, while another resident faced issues with wheelchair bearings that were not addressed despite repeated requests. The facility's grievance log did not accurately reflect these concerns, and no effective resolution was provided.
The facility failed to ensure proper medication storage and security across all units. Expired and improperly stored medications were found in medication carts, and unsecured medications were accessible in an office. Additionally, residents had medications in their rooms without authorization for self-administration, violating the facility's policy.
The facility failed to ensure accurate PASARR Level I screens for three residents, leading to deficiencies. A resident with PTSD and depression, another with depression, and a third with anxiety disorder had screens that did not reflect their mental health diagnoses. The DON confirmed the inaccuracies, and the Admission Director admitted to not checking for accuracy due to lack of training.
A resident with a history of muscle wasting and impaired mobility was not provided with a contracture management care plan, resulting in a deficiency. Despite having a prescribed right-hand splint, the resident was observed multiple times without it, and there was no documentation of its use. Interviews revealed that the resident was aware of the splint's purpose but was not assisted by staff in wearing it. Occupational therapy staff were responsible for its application, but there was no documentation of consistent use.
A resident in a long-term care facility did not receive necessary nail care assistance, resulting in long, untrimmed nails with debris. Despite the resident's desire for nail care, there was no documentation of care being provided or refused. The care plan lacked specific instructions for nail care refusal, and staff interviews revealed challenges in providing care due to the resident's refusals. The facility's policies required documentation of refusals, but this was not consistently done, and grievances regarding nail care were not adequately addressed.
A resident with a history of malignant neoplasm of the larynx and COPD did not receive enteral nutrition as ordered, with the feeding pump often found off and not running. Despite orders for continuous feeding at 65 ml/hr, observations confirmed the feeding was not administered as prescribed. Staff interviews revealed awareness of the orders, but the feeding was not ensured, leading to a deficiency in care.
The facility failed to implement pharmacy recommendations for two residents, leading to deficiencies in medication management. A resident with COPD did not have a recommended reminder to rinse the mouth after using an inhaler added to their physician's order. Another resident with multiple diagnoses had several pharmacy recommendations unaddressed, including clarifying medication orders and evaluating medication use due to fall risk. The DON confirmed these recommendations were not followed up with the physician.
A facility experienced a 10% medication error rate due to three incidents involving incorrect medication administration. An LPN administered the wrong medication to a resident due to similar packaging, another resident missed a dose of Entresto due to a reorder delay, and a third resident received an incorrect dosage of Risperidone due to a charting system error. The errors were acknowledged by staff, and the Director of Nursing reviewed the issues.
A resident with scabies did not receive proper infection control measures, as prescribed treatments were not administered, and staff were unaware of the diagnosis. The facility failed to implement isolation and cleaning protocols, leading to a deficiency in infection control practices.
Resident With Post-Surgical Abdominal Complications Called 911 After Facility Response to Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident’s right to appropriate, respectful care and self-determination in the context of post-surgical complications and worsening abdominal symptoms. The resident had a complex medical history including chronic pancreatitis, a Whipple procedure, splenectomy, prior Serratia bacteremia with suspected urinary or abdominal source, and a recent surgical drain that was later removed. After drain removal, the resident experienced gradually increasing abdominal distention and pain at the drain site, followed by significant abdominal pain, swelling, fevers, chills, and inability to tolerate oral intake in the 24 hours prior to hospital evaluation. Hospital assessment documented leukocytosis with left shift and CT findings of gastritis with inflammation near the prior drain site and two postoperative fluid collections or possible pseudocysts, raising concern for infected fluid collections or recurrent pancreatitis-related complications. Within the facility, the RN/Unit Manager reported that the resident was there for recovery after laparoscopic surgery, had complications at home requiring readmission and a drain, and then returned with the drain removed “without complications,” later developing pain. The RN/Unit Manager stated there was an order for a dressing that came off and that the resident “was fine,” and described the facility’s usual process when a resident has a change in condition and wants to go to the ER as assessing first, reviewing vital signs, and determining if the issue can be treated in the facility. For this resident, staff provided pain and nausea medication, but the resident ultimately called 911 independently to go to the hospital, rather than the nurse initiating the call as is “usually” done. The RN/Unit Manager stated, “I don’t know what happened,” and did not know the resident’s condition upon admission to the hospital, indicating a lack of clear facility action and communication around the resident’s change in condition and transfer, in the context of the resident’s right to appropriate care and access to needed services.
Plan Of Correction
Corrective Action for Resident Affected: The resident was transferred and evaluated for appropriate medical services. Resident #5 no longer resides in the facility. Identification of Other Residents at Risk: An audit was conducted on residents with recent changes in condition, emergency transfers, and documented requests for outside medical services from the past 30 days to identify any additional requests to be sent out for medical necessity. No other residents were identified. Systemic Changes Implemented: The Director of Nursing or designee re-educated licensed nurses, and interdisciplinary staff on resident rights related to accessing medical care and services outside the facility, including timely physician notification, emergency response procedures to prevent delayed emergent care, and honoring resident/responsible party requests for outside medical evaluation. Monitoring to Ensure Compliance: The Director of Nursing/designee will audit return to hospital/transfers change in condition and resident requests for outside medical services weekly for four
Failure to Honor Resident’s Request for Hospital Transfer and Delay in Emergent Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to seek medical services outside the facility, resulting in delayed emergent care. A resident with diagnoses including pancreatic disease, immune disorder, anemia, and muscle wasting had previously undergone a laparoscopic distal pancreatectomy with sphincterotomy and partial gastrectomy. Following admission to the facility, the resident developed symptoms of pain, bloating, vomiting, and later diarrhea after surgery. Progress notes show that on one day in the afternoon, a nurse called and left a message for the MD regarding the resident’s condition, and later that night the resident complained of pain and vomiting, the MD was notified, pain medication frequency was increased, and milk of magnesia was ordered and given. The note also indicated a need to call the MD for IV normal saline to prevent dehydration per family request, but documented that the MD was called with no response. The next day around midday, documentation shows the resident complained of stomach pain and was insisting on going to the hospital, with vital signs recorded as temperature 97.3, pulse 104, respirations 18, blood pressure 173/99, and oxygen saturation 97%. The nurse documented that the doctor was paged to advise. Later that afternoon, staff documented returning from lunch and finding paramedics at the resident’s room, and that the resident had called paramedics to be taken to the hospital. Hospital records from that day show the resident was admitted with a chief complaint of sepsis and suspected pseudocyst, with a history of similar abdominal symptoms and prior imaging showing pancreatic duct stricture and dilation. In interviews, the resident’s family member reported being upset and frustrated because staff did not want to send the resident to the ER despite the resident’s request to go to the hospital after experiencing pain, bloating, vomiting all night, and subsequent diarrhea. The family member stated that a nurse said the in-house doctor would assess the resident first, that the resident had a pail of vomit at bedside, and that the family begged the nurse to send the resident out but she would not. The family member reported calling non-emergency police for a wellness check and advising the resident to call 911 herself, after which the resident was transported. CNAs recalled the resident becoming very sick and throwing up frequently. The DON acknowledged hearing that the resident was sick and that police had been at the facility, and confirmed that if a resident wanted to go to the hospital, the nurse should assess, notify the physician, document vitals and monitoring, and assist the resident in seeking outside medical care. Review of the facility’s Resident Rights policy showed the facility is required to protect and promote residents’ rights, including assisting them in maintaining communication with outside agencies and ensuring they can exercise their rights without interference, coercion, discrimination, or reprisal.
Plan Of Correction
Continued from page 1 Weeks, then monthly for two weeks to ensure timely response to resident requests to go out to the hospital. Audit findings will be reported through the facility's Quality Assurance Committee monthly until substantial compliance is met.
Failure to Provide Necessary Nail Care for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL services, specifically nail care, to a dependent resident with quadriplegia. The resident was admitted with diagnoses including unspecified quadriplegia, muscle wasting and atrophy, and other lack of coordination, and had documented ADL self-care performance deficits and impaired range of motion in all extremities. During an observation and interview, the resident’s fingernails were noted to be approximately one to one and a half inches long. The resident reported that he had been requesting nail trimming from his assigned CNA for the past three days, but was repeatedly told variations of “not yet” or that the CNA was on break or it was change of shift. He stated that his nails had last been cut by a family member about six weeks earlier, and that the DON had been informed of his request for nail trimming by a psychiatry provider. A telephone interview with the family member confirmed that she had last cut his nails approximately six weeks prior. Review of the resident’s nail care task documentation from 3/28/26 to 4/23/26 showed entries of “No Nail Care,” with one entry of “Resident Refused” on 3/30/26, and no evidence that nail care had been provided in the last 30 days. The assigned CNA stated that nail care was supposed to be completed every weekend or as needed, and that staff should perform nail care whenever a resident requested it, but also reported that staffing shortages delayed their ability to cut residents’ nails. She indicated that the resident’s nails were last cut about a month ago by a family member and that she planned to cut his nails that day because he had asked. The DON and RN/Unit Manager stated that CNAs or nurses provided nail care depending on diagnosis, that nail care should be done if a resident requested it, and that nail care was part of hygiene and infection control, but they were not sure where completion or refusal of nail care should be documented and could not confirm documentation of prior refusals. The facility did not provide a policy related to ADLs or nail care.
Plan Of Correction
Corrective Action for Resident Affected: Nail care was provided to Resident#4. Identification of Other Residents at Risk: Director of Nursing or designee conducted a house-wide audit to identify residents in need of nail care. Any identified concerns were addressed, and nail care services were provided as indicated. Systemic Changes Implemented: The Director of Nursing or designee re-educated the Licensed Nurses and certified Nursing assistants on resident nail care requirements, including timely identification and reporting of nail care needs. Licensed Nurses and Certified Nursing Assistants were educated on documenting completion of nail care in the electronic health record and communicating unmet care needs to nursing supervision. Monitoring to Ensure Compliance: The Director of Nursing or designee will conduct weekly audits of residents requiring nail care needs are addressed and documented appropriately. Random audits will be completed weekly for four weeks, then monthly for two months. Findings will be reviewed during the facility's Quality Assurance Committee meetings, until substantial compliance is met.
Failure to Implement Diet-Related Physician Order for Double Portions
Penalty
Summary
The facility failed to implement a physician’s diet-related order for double portions at all meals for one resident. Surveyors observed the resident’s lunch meal and noted the tray ticket did not indicate large or double portions. Record review showed the resident was admitted with diagnoses including unspecified quadriplegia, muscle wasting and atrophy of multiple sites, and other lack of coordination. Physician orders included a house diet with regular texture and thin liquids, no pork, and lactose intolerance restrictions starting in January, and an additional order starting in March that the resident may have double portions for all meals six times a day. The resident’s care plan and nutrition evaluation documented that the resident requested large entrée portions at meals and that large portions were to be provided per the resident’s request. Interviews and further record review revealed that the Food Service Manager (FSM) confirmed the resident received large portions at breakfast only, and that the lunch and dinner meal tickets did not show large portions. The FSM explained that dietary orders entered into the electronic medical record are automatically transferred to the meal tracker system, which prints the meal tickets, and that he could not adjust orders himself. He stated he did not see the double-portion order because it was categorized as “other” rather than under dietary. The DON reported that diet orders are to be entered by nursing leadership or the RD, documented on a dietary slip, and provided to dietary personnel, and confirmed that the double-portion order had been incorrectly entered under the “other” category and not communicated properly to dietary. The facility did not provide a policy related to physician or dietary orders.
Plan Of Correction
Formatted text (without <text> tags or quotes): Corrective Action for Resident Affected:Resident #4 was evaluated by nursing staff and theDietician to ensure the physician-ordered diet wasimplemented accurately. The order was changed inthe electronic health record and on the meal ticket toadd large portions to breakfast, lunch, and dinner. Identification of Other Residents at Risk:The Dietician and Clinical Reimbursement Directorcompleted an audit of current residents with physician-ordered dietary interventions to ensure dietary orders were accurately transcribed both in the electronic health record and displayed accurately on the meal ticket. Any discrepancies identified were corrected as indicated. Systemic Changes implemented: The Director of Nursing/designee re-educated Licensed nurses on the importance of implementing physician-ordered diets as written in the electronic health record. Education included the process for verifying diet orders following admissions, readmissions, and physician changes. Monitoring to Ensure Compliance: The Director of Nursing and/or Dietary Manager/designee will conduct audits of physician-ordered diets and meal tray accuracy weekly for four weeks, then monthly for two months to ensure compliance with ordered dietary interventions. Audit findings will be reviewed during the facility's Quality Assurance Committee meetings until substantial compliance is met.
Failure to Provide Nail Care, Implement Diet Orders, and Support Resident’s Right to Outside Medical Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate and appropriate health care and services, including basic ADL support and implementation of physician diet orders, as well as failure to support a resident’s right to seek outside medical care. For one resident with quadriplegia and muscle wasting, surveyors observed fingernails approximately one to one and a half inches long. The resident reported he had been asking his assigned CNA for nail trimming for three days, but was repeatedly told to wait because the CNA was on break or it was change of shift. He stated his nails had last been cut by a family member about six weeks earlier, which the family member confirmed. Documentation of nail care tasks over the prior 30 days showed no nail care provided, with only one entry indicating resident refusal, and the facility could not produce a policy specific to ADLs or nail care. Staff interviews further showed inconsistent understanding and implementation of nail care. The CNA typically assigned to this resident stated nail care should be done every weekend or as needed and that staff should cut nails whenever a resident asks, but also reported staffing shortages that delayed nail care. She acknowledged the resident’s nails had last been cut by family about a month earlier and that nail care was considered a PRN task documented in the Kardex, although the DON and RN/Unit Manager were unsure where nail care completion was documented. The DON stated nail care was part of hygiene and infection control, should be done when requested, and that refusals should be documented, but she could not confirm documentation of prior refusals for this resident. The resident’s care plan identified ADL self-care deficits related to quadriplegia and the need for assistance with ADLs, but there was no evidence that requested nail care was provided or consistently documented. The same resident also had a physician order for double portions for all meals, which was not fully implemented. The medical record showed a house diet with specific restrictions and an order allowing double portions for all meals six times a day. The nutrition evaluation documented that the resident requested large entrée portions and that large portions were to be provided. However, observation of a lunch meal showed the tray ticket did not indicate large or double portions. The Food Service Manager reported the resident received large portions at breakfast only, and review of meal tickets confirmed that only breakfast was marked for large portions, while lunch and dinner were not. The FSM explained that diet orders entered in the EMR automatically transfer to the meal tracker system and that he could not adjust them; he stated the double-portion order had been categorized under “other” rather than dietary, so it did not appear correctly in the dietary system. The DON confirmed that the double-portion order had been miscategorized and that a dietary slip should have been written and handed to dietary staff but was not. A separate deficiency involved the facility’s failure to protect a resident’s right to seek medical services outside the facility, resulting in delayed emergent care. One resident, admitted with diagnoses including pancreatic disease, immune disorder, anemia, and muscle wasting, had undergone a distal pancreatectomy with partial gastrectomy and later had a surgical drain removed. According to the resident’s family member, the resident developed pain, bloating, vomiting, and diarrhea and requested to go to the hospital, but a nurse stated the in-house doctor would assess first. The family member reported that the resident was given nausea medication, continued to have symptoms through the night and into the next day, and that he repeatedly begged the nurse to send the resident out. He stated the resident had a pail of vomit at bedside and that he eventually called non-emergency police for a wellness check and advised the resident to call 911 herself, after which she was transported to the hospital. Progress notes documented that a call was placed to the MD regarding the resident’s condition, that later that evening the resident complained of pain and vomiting and the MD was notified, resulting in a change in pain medication frequency and an order for milk of magnesia. The note also indicated a request to obtain an order for IV fluids to prevent dehydration per family request, but stated the MD was called with no response. The following day, documentation showed the resident complained of stomach pain and insisted on going to the hospital, with vital signs recorded and the doctor paged. A later note recorded that paramedics were at the resident’s room and that the resident had called them to be taken to the hospital. Hospital records from that day showed the resident presented with worsening abdominal pain, swelling, systemic symptoms, leukocytosis with left shift, and CT findings of gastritis with inflammation near the prior drain site and postoperative fluid collections or possible pseudocysts. Staff interviews revealed gaps in assessment, monitoring, and support for the resident’s request to go to the ER. The RN/Unit Manager stated that when a resident has a change and wants to go to the ER, the nurse should assess, review vital signs, and determine if the issue can be treated in the facility, and acknowledged the resident was given pain and nausea medications and ultimately went to the hospital after calling 911 herself. She stated she did not know what happened at the time of transfer. CNAs recalled the resident as ambulatory and noted she was “getting sick towards the end” and “throwing up all the time,” but did not recall the exact timeline or whether she was sent out immediately. The DON stated she had heard police were involved for this resident but did not get details, and confirmed that if a resident wants to go to the hospital, the nurse should assess, notify the physician, document vitals and monitoring, and assist with transfer. She agreed that if it was not documented, it did not happen, and acknowledged the resident has a right to seek medical care and should be assisted in doing so.
Plan Of Correction
Corrective Action for Resident Affected: Nail care was provided to Resident#4. Identification of Other Residents at Risk: Director of Nursing or designee conducted a house-wide audit to identify residents in need of nail care. Any identified concerns were addressed, and nail care services were provided as indicated. Systemic Changes Implemented: The Director of Nursing or designee re-educated the Licensed nurses and certified nursing assistants on resident nail care requirements, including timely identification and reporting of nail care needs. Licensed Nurses and Certified Nursing Assistants were educated on documenting completion of nail care in the electronic health record and communicating unmet care needs to nursing supervision. Monitoring to Ensure Compliance: The Director of Nursing or designee will conduct weekly audits of residents requiring nail care needs are addressed and documented appropriately. Random audits will be completed weekly for four weeks, then monthly for two months. Findings will be reviewed during the facility's Quality Assurance Committee meetings, until substantial compliance is met.
Medication Error Rate Exceeds 5% Due to Improper Administration and Documentation
Penalty
Summary
Surveyors identified that the facility failed to maintain a medication error rate below 5%, with observations revealing a 68.18% error rate during medication administration to two residents. During medication passes, staff administered incorrect medications, failed to follow manufacturer instructions for insulin administration, and did not adhere to facility policy regarding hand hygiene and documentation. Specifically, one LPN used an insulin syringe to extract insulin from a pen, contrary to manufacturer warnings and facility policy, due to a lack of appropriate pen needles. The same staff member also administered a probiotic that was not the one ordered and failed to notify the physician about late or missed medications. Another LPN was observed administering multiple medications late, failing to perform hand hygiene or wear gloves when administering eye drops, and documenting that a resident received medication that was actually refused. Additionally, scheduled doses of inhaled medications and topical treatments were not administered as ordered, and documentation did not reflect accurate administration times or refusals. Interviews with staff confirmed that medication administration was delayed due to staffing issues and meetings, and that there had been an ongoing shortage of insulin pen needles, which had not been adequately addressed by facility leadership. Review of facility policies showed clear requirements for medication administration timing, hand hygiene, and proper use of insulin pens, none of which were consistently followed. The DON and other staff acknowledged the lack of pen needles and the resulting improper insulin administration practices, as well as gaps in communication with pharmacy and among staff. The pharmacy confirmed a recent shortage of pen needles, but the facility had not implemented alternative solutions or ensured compliance with safe medication administration practices.
Failure to Implement Effective Infection Control Practices During Medication Administration
Penalty
Summary
Surveyors observed multiple failures in the facility's infection prevention and control practices during medication administration and resident care. One staff member was seen extracting insulin with a safety sheath syringe, then placing the unsheathed needle on various surfaces, including a mouse pad and a medication blister card, before entering a resident's room. The same staff member placed the unsheathed syringe, along with a cup of water and a glucometer, directly on a resident's over bed table without using a barrier. These actions were confirmed by the staff member when questioned. Another staff member was observed with natural fingernails extending approximately half an inch past the fingertips, which is contrary to facility policy and CDC guidance. This staff member administered multiple medications, including eye drops, to a resident without performing hand hygiene or donning gloves. The staff member acknowledged not using hand sanitizer and not wearing gloves during the administration of eye drops. Additionally, a unit manager was observed with similarly long, painted fingernails, further indicating non-compliance with infection control standards. The Director of Nursing confirmed that hand hygiene is required before and after glove use and during medication administration, but was uncertain about the specific policy on fingernail length. Review of the facility's employee handbook and infection prevention policy revealed requirements for short, clean fingernails and no artificial nails, as well as comprehensive infection control measures. CDC guidance also emphasizes the importance of hand hygiene and maintaining short natural nails to prevent the spread of infection.
Failure to Maintain Sanitary and Homelike Environment in Shared Shower Areas
Penalty
Summary
Surveyors observed that the facility failed to maintain a sanitary and homelike environment in the main shower room and two shared bathrooms. Specific findings included clumps of hair and debris in the main shower room drain, a shower chair with a cup containing a green substance and black particles, and black debris inside a bedpan left on a shower chair. Additional observations revealed multiple strands of hair and areas of black and green bio-growth on the floors and tiles in the shared bathrooms. These unsanitary conditions were present in three out of thirteen rooms with shared bathrooms. Interviews with housekeeping staff revealed inconsistent cleaning practices and unclear responsibilities regarding the cleaning of showers and shower chairs. One staff member stated he only cleaned toilets and mirrors, while another indicated that CNAs were responsible for cleaning after each resident and that he only performed basic cleaning unless notified of an issue. The housekeeping supervisor confirmed that showers should be cleaned regardless of use and that the observed bio-growth would not have developed overnight. Facility policy requires a safe, clean, and comfortable environment, including clean resident care equipment, but these standards were not met in the areas observed.
Failure to Assess and Respond to Resident Fall Resulting in Delayed Treatment
Penalty
Summary
A resident with multiple medical conditions, including dementia, muscle weakness, osteoarthritis, and a history of falls, experienced an unwitnessed fall in their room. The resident's roommate reported hearing a loud noise and the resident expressing pain, after which she activated the call light and called for staff assistance. Staff response was delayed, and when they arrived, the resident was assisted back to bed without a documented assessment or evaluation for injuries as required by facility protocol. No documentation of the fall or post-fall assessment was found in the medical record for the date of the incident. Over the following days, the resident continued to complain of hip pain, which was reported by the roommate to staff on multiple occasions. It was not until two days after the fall that staff documented the resident's complaints and ordered an X-ray, which revealed a right hip fracture. The resident was subsequently transferred to a hospital for surgical intervention. The facility's own investigation confirmed that the assigned nurse failed to perform or document a post-fall assessment, did not notify supervisory staff, the physician, or the resident's family, and did not follow established protocols for managing unwitnessed falls and changes in condition. Facility policies required a full post-fall assessment, including neurological checks and range of motion evaluation, before moving a resident after a fall, as well as timely notification of the physician, family, and supervisory staff in the event of a significant change in condition. These procedures were not followed in this case, resulting in a delay in identifying and treating the resident's injury. The deficiency was substantiated through interviews, record reviews, and policy comparisons, which demonstrated a failure to protect the resident from neglect and to ensure their right to be free from abuse and neglect.
Failure to Provide Required Transfer Assistance Resulting in Resident Injury
Penalty
Summary
A resident with a history of cerebrovascular accident, hemiplegia, and recent femur fracture was care planned for total mechanical lift transfers with two staff assistance. The resident was dependent for transfers and required a large sling size, as documented in the care plan and supported by therapy and nursing assessments. On the day of the incident, the resident was transferred by a single CNA without a second staff member, contrary to the care plan and facility policy, which required two-person assistance for mechanical lift transfers. During the transfer, the resident fell, resulting in significant pain and an acute left femoral shaft fracture with intra-articular extension to the knee joint, as confirmed by hospital records and imaging. Multiple interviews and documentation revealed inconsistencies in staff and resident accounts, but it was ultimately determined through investigation and reenactment that the CNA performed the transfer alone. The mechanical lift was present in the room, but the required second staff member was not involved in the transfer process. Facility policies on abuse prevention, safe operation of resident lifts, and fall and injury reduction all required adherence to care plans and manufacturer recommendations, including the use of two staff for mechanical lift transfers when indicated. The failure to follow these protocols and provide the necessary assistance directly resulted in the resident's fall and injury, constituting neglect as defined by facility policy.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours each day, seven days a week, during the period from 4/6/25 to 4/12/25. Review of the staff schedule for 4/5/25 - 4/6/25 showed that all nursing shifts were staffed by Licensed Practical Nurses (LPNs), and the only RN listed had their name crossed out. This indicates that no RN was present on those shifts as required. During an interview, the Director of Nursing (DON) acknowledged that staffing is determined based on census and that there have been instances where staff did not come in as scheduled, often discovered only after the fact. The DON confirmed that the facility is supposed to have an RN on duty and suggested that the RN may have called off, but she was unaware of the specifics as she was out of town at the time. The facility's policy requires daily monitoring and adjustment of staffing to ensure compliance with federal and state requirements, but this was not effectively implemented during the cited period.
Failure to Ensure Competent Nursing Care, Accurate Medication Documentation, and Timely Family Notification
Penalty
Summary
Nursing staff failed to demonstrate appropriate competencies and skills in the care of a resident with significant mobility impairments and a history of cerebrovascular accident, resulting in multiple deficiencies. The resident, who was non-ambulatory and dependent on a mechanical lift with two-person assistance for transfers, sustained a severe left femoral fracture after being transferred by a single CNA without the use of the mechanical lift as required by the care plan. Interviews and documentation revealed that the CNA attempted the transfer alone, contrary to facility policy and the resident's care plan, and the incident was initially misrepresented in statements and reenactments. The resident reported that the mechanical lift was not used, and the CNA confirmed during reenactment that she performed the transfer alone. The nurse on duty did not witness the transfer but confirmed the lift was present in the room and that the resident was lifted from the floor without the mechanical lift after the fall. Additionally, there were significant discrepancies in the documentation of controlled medication administration for the same resident. A review of the Medication Administration Record (MAR) and controlled drug inventory sheets for oxycodone revealed multiple instances where doses were recorded on one document but not the other, as well as inconsistencies in administration times. The Director of Nursing confirmed these discrepancies upon review, which were not in accordance with facility policy requiring immediate and accurate documentation of controlled substance administration on both the MAR and inventory sheets. Furthermore, the facility failed to notify the resident's emergency contact or family member following the resident's transfer to an acute care facility after the fall. Documentation in the medical record and transfer forms did not indicate that the family was notified, and interviews with the resident's family confirmed they were not informed by the facility and only learned of the hospitalization through the resident herself. Facility policy required notification and documentation of such changes in condition, which was not followed in this instance.
Failure to Notify Emergency Contact of Resident Hospitalization
Penalty
Summary
The facility failed to notify the designated emergency contact of a significant change in condition for a resident who experienced a fall resulting in hospitalization. The resident had multiple diagnoses, including a femur fracture, hemiplegia, and other mobility impairments, and was dependent on staff for care. Documentation reviewed, including the SNF/NF to hospital transfer form, SBAR Communication Form, and Progress Notes, did not show evidence that the family member or emergency contact was notified of the resident's transfer to the hospital. Interviews with the resident and her family member confirmed that the family was not informed by the facility and only learned of the hospitalization from the resident herself, after the fact. Staff interviews revealed that while the RN notified the DON and the physician about the resident's change in condition and subsequent transfer, there was no documentation or confirmation that the family was contacted. The DON acknowledged that facility policy requires staff to notify the resident's representative in the event of a significant change and to document this notification in the medical record. A review of the risk event note with the DON confirmed the absence of documentation regarding family notification. The facility's policy also specifies that such notifications and documentation are required.
Failure to Accurately Document and Account for Controlled Substances
Penalty
Summary
The facility failed to maintain accurate accounting and documentation of narcotic medication administration for a resident who was cognitively intact and dependent on staff for transfers following recent leg surgery. The resident was prescribed oxycodone for pain management, with orders changing from 5 mg to 10 mg tablets during the month. Review of the resident's Medication Administration Record (MAR) and Controlled Drug Declining Inventory Sheets revealed multiple discrepancies. Specifically, several doses of oxycodone were documented as administered on the inventory sheets but were not recorded on the MAR, and there were inconsistencies in the times of administration between the two records. The Director of Nursing confirmed these discrepancies upon review, acknowledging that staff are required to document administration in both the electronic record and the inventory sheet at the time of administration. Facility policy mandates immediate and accurate documentation of controlled substances, including date, time, amount administered, and nurse signature, in accordance with federal and state regulations. The observed failures included missing entries and mismatched times between records, resulting in an inability to accurately reconcile the receipt and disposition of controlled drugs for the resident.
Excessive Sanitizer Concentration in Dishwashing Machine
Penalty
Summary
The facility failed to ensure the kitchen dishwashing machine was operating at optimum levels, specifically regarding the concentration of the chemical sanitizer. During an observation on 2/11/2025, it was found that the dishwashing machine's chemical chlorine sanitizer delivery system was excessively concentrated, with levels well over 100 parts per million (ppm), exceeding the required range of 50-100 ppm. Staff A, the Dietary Manager, confirmed this observation after conducting litmus tests that showed a very dark purple color, indicating high concentration levels. Despite this, the machine continued to be used for meal services on 2/11/2025 and 2/12/2025 without corrective action. The issue was compounded by the fact that the facility had previously been cited for a similar violation during a county Department of Health inspection on 1/24/2025, which recommended using manual sanitation until the dish machine was repaired. Although the machine was reportedly repaired two days after the inspection, Staff A was unaware of the overconcentration issue until the surveyor's observation. Additionally, there was no documentation of in-services or education provided to the dietary staff regarding the dishwashing machine's operation since the health department's inspection. Furthermore, Staff A did not have access to the dishwashing machine's operations manual or a policy related to its operating procedure.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to maintain a sanitary and safe environment for residents across two units, as observed over three consecutive days. In one resident's bathroom, a recent wall repair was inadequately covered, leaving a torn panel and missing trash can, while the toilet tank lacked a lid. Another shared bathroom had a rusted glove box holder and a door with peeling paint, creating non-cleanable surfaces. The Director of Maintenance and the housekeeping director were unaware of these issues, indicating a lapse in communication and oversight. Additional observations revealed unsanitary conditions in several rooms, including brown substances around toilet bases, bio-growth on shower chairs and tiles, and missing or malfunctioning fixtures such as light bulbs and toilet paper holders. A room's privacy curtain was stained, and the bathroom had cracked tiles with debris. The Director of Maintenance was not informed of these issues through work orders, and the housekeeping manager was unaware of the stained curtain, suggesting a breakdown in reporting and maintenance processes. Further deficiencies included broken and non-cleanable surfaces in resident rooms, such as a detached handrail, a broken glove box, and an armchair with worn material. The Regional President confirmed these issues during an inspection, noting that repairs and replacements were necessary. The facility's policy mandates a safe and clean environment, yet the observations and interviews indicate a failure to adhere to these standards, as evidenced by the lack of awareness and action from maintenance and housekeeping staff.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure prompt resolution of grievances for two residents, leading to deficiencies in addressing their concerns. Resident #33 reported that their wheelchair was lost during a hurricane evacuation and was not replaced with a suitable one upon return. Despite notifying the Social Service Director (SSD) about the issue, the resident's grievance was not documented in the grievance log, and no resolution was provided, leaving the resident with an ill-fitting wheelchair. Resident #13 expressed concerns about the bearings of their wheelchair, which were causing mobility issues. Although the resident communicated this issue to staff and was offered a new wheelchair, they declined, preferring to have the bearings fixed. The grievance log did not reflect this specific concern, and the Director of Maintenance (DOM) confirmed that no action was taken to order the necessary parts for repair. The SSD acknowledged the unresolved nature of the grievance, indicating a failure to address the resident's specific request.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications across all three units, leading to multiple deficiencies. On the central unit, a medication cart audit revealed expired Sodium Bicarbonate and a dirty cart with debris and packaging materials. Staff H, an LPN, acknowledged the cart's unclean state and the presence of expired medication, attributing the oversight to the night shift's failure to clean and check for expired medications. Similarly, on the north unit, an audit of another medication cart found expired Bisacodyl suppositories, a loose pill, and improper storage of medical gloves with narcotics. Staff E, an RN, confirmed these issues and admitted a lack of awareness regarding proper storage protocols. Additionally, unsecured medications were found in an office on the main unit, accessible to residents, including those with cognitive impairments. The office, belonging to Staff D, an RN, was left unlocked with a box of medications on the floor, posing a risk to residents who frequently passed by. Staff D explained that the medications were meant to be returned to the pharmacy and acknowledged the potential issues arising from the unsecured storage. Furthermore, several residents were observed with medications in their rooms without proper authorization for self-administration. Resident #65 had a cup with multiple pills on their bedside table, and other residents had inhalers and anti-diarrheal medication on their tables. The facility's Director of Nursing confirmed that no residents had orders for self-administration, indicating a failure to adhere to the facility's medication storage policy, which mandates that medications be accessible only to authorized personnel and stored securely.
Inaccurate PASARR Level I Screens for Residents
Penalty
Summary
The facility failed to ensure accurate completion of Preadmission Screening and Resident Review (PASARR) Level I screens for three residents. Resident #64 was admitted with a diagnosis of post-traumatic stress disorder and was prescribed Bupropion for depression. However, the PASARR Level I screen did not indicate any mental illness. The Director of Nursing (DON) confirmed the screen was incorrect and should have been updated. Similarly, Resident #65, who had a diagnosis of depression and was on antidepressant medication, had a PASARR Level I screen that did not reflect this diagnosis. The DON acknowledged that the screen should have been checked and updated upon admission. Resident #40 was admitted with a diagnosis of anxiety disorder, yet their PASARR Level I screen did not indicate this condition. The DON confirmed that the screen should have been updated to reflect the diagnosis. The facility's policy requires that PASARR screenings be conducted prior to admission and reviewed for accuracy, but the Admission Director stated that she did not check for accuracy and had not received training to do so. The DON was responsible for reviewing and updating PASARR screens based on diagnoses and medications, but this process was not adequately followed, leading to the deficiencies identified.
Failure to Implement Contracture Management Care Plan
Penalty
Summary
The facility failed to develop a contracture management splinting care plan with goals and interventions for a resident, leading to a deficiency. The resident, who has a history of muscle wasting, impaired mobility, and a cerebrovascular accident, was observed multiple times without the prescribed right-hand splint/orthotic. Despite the presence of the splint in the resident's room, it was not applied by staff, and there was no documentation of its use in the care plan or medical records. Interviews with the resident revealed that he was aware of the splint and its purpose to alleviate pain, but he was not assisted by staff in wearing it. The resident's right hand showed signs of contracture, and he was observed using his left hand to stretch his contracted fingers. The resident confirmed that staff had previously assisted him with the splint, but it was no longer being applied. Further investigation showed that the occupational therapy staff was responsible for the application of the splint, but there was no documentation to support its consistent use since its delivery. The facility's policy requires that care plans include measurable objectives and interventions to maintain residents' well-being, but this was not adhered to in the case of the resident's contracture management.
Failure to Provide Adequate Nail Care to Resident
Penalty
Summary
The facility failed to provide necessary nail care to a resident who required assistance with activities of daily living (ADL). Observations on two consecutive days revealed that the resident had long, untrimmed fingernails with dark debris underneath, and the resident could not recall when he last received nail care. Despite the resident expressing a desire to have his nails trimmed, there was no documentation of nail care being provided or refused in the resident's records. The resident's care plan indicated a need for assistance with personal hygiene, but there was no specific care plan addressing nail care refusal, despite known refusals since October 2024. Interviews with staff revealed that the Certified Nursing Assistant (CNA) responsible for the resident's care found it challenging to provide nail care due to the resident's refusals. The Director of Nursing (DON) acknowledged that refusals should be documented and care planned, but there was no evidence of such documentation or care planning. The facility's policies required CNAs to provide nail care during showers and document any refusals, but there was a lack of consistent documentation and follow-up. The Social Services Director confirmed that grievances had been filed regarding the resident's nail care, and although some resolutions were attempted, the issue persisted without a proper care plan in place. The facility lacked an ADL policy, relying instead on care plans that were not adequately updated to reflect the resident's needs and refusals.
Failure to Administer Enteral Nutrition as Ordered
Penalty
Summary
The facility failed to provide enteral nutrition per physician orders for a resident with enteral nutrition orders. The resident, who had a medical history including malignant neoplasm of the larynx and chronic obstructive pulmonary disease, was observed multiple times with the enteral feeding pump not running, despite having an order for continuous feeding at 65 ml/hr. Observations over several days showed that the enteral feeding pump was often off, and the feeding formula was not being administered as prescribed. The resident reported that the pump had not been running, and the observations confirmed that the feeding was not being delivered as ordered. Interviews with staff revealed that the registered nurse was aware of the order for continuous feeding but had not ensured the feeding was administered as prescribed. The registered dietitian expressed concern about the missed nutrition, and the Director of Nursing acknowledged the need to investigate the handling of the resident's orders. The facility's policy emphasized optimizing nutritional status in accordance with the resident's wishes, but the lack of adherence to the physician's orders resulted in a deficiency in care for the resident.
Failure to Implement Pharmacy Recommendations for Two Residents
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were implemented for two residents, leading to deficiencies in medication management. Resident #64, who was admitted with chronic obstructive pulmonary disease (COPD), had a physician's order for Breo Ellipta Inhalation Aerosol. The consultant pharmacist recommended adding a reminder to rinse the mouth after using the inhaler to prevent oral thrush, but this recommendation was not signed, reviewed, or completed. As of February 11, 2025, the physician's order had not been updated to include the recommended verbiage. Resident #2, admitted with multiple diagnoses including COPD, epilepsy, and major depressive disorder, had several pharmacy recommendations that were not addressed. The consultant pharmacist suggested clarifying and updating medication orders and evaluating the use of certain medications due to their potential to cause falls. Despite these recommendations, the physician's orders remained unchanged as of February 12, 2025. The Director of Nursing confirmed that the pharmacy recommendations for both residents had not been addressed and should have been referred to the physician for follow-up. The facility also failed to provide the requested policy and procedure for pharmacy recommendations.
Medication Administration Errors Lead to 10% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 10% error rate during the survey. Three medication errors were identified involving three residents. For Resident #32, a Licensed Practical Nurse (LPN) administered Cetirizine HCL instead of the prescribed Claritin. The LPN acknowledged the error, noting that the medications were stored close together in the cart, leading to the mistake. Resident #36 did not receive their prescribed Entresto due to it not being available in the medication cart. The medication had not been reordered in time, and there was no documentation that the physician was notified of the missed dose. Interviews with the facility's pharmacy and the resident's primary care physician confirmed the lack of communication regarding the missed medication. For Resident #11, an LPN administered 1.5 ml of Risperidone instead of the prescribed 1.0 ml for the morning dose. The error occurred because the electronic charting system displayed the bedtime dosage alongside the morning order, leading to confusion. The Director of Nursing reviewed the orders and acknowledged the potential for error due to the system's display issue.
Inadequate Infection Control for Scabies Case
Penalty
Summary
The facility failed to ensure proper infection control practices for a resident diagnosed with scabies. The resident, who was cognitively intact, reported itching and had visible scabbed spots on her legs. Despite being prescribed Permethrin cream for scabies, the medication was not administered as ordered, and the resident continued to experience symptoms. The facility's records showed inconsistencies in the administration of Ivermectin, with several doses marked as not given or awaiting pharmacy delivery. Interviews with staff revealed a lack of awareness and communication regarding the resident's scabies diagnosis. The LPN responsible for the resident was unaware of the scabies treatment, and the RN/Unit Manager did not recognize the need for isolation or room cleaning. The Director of Nursing and the Nursing Home Administrator were also unaware of the scabies case, indicating a breakdown in communication and adherence to the facility's scabies management policy. The facility's policy required contact precautions, isolation, and thorough cleaning of the resident's room, none of which were implemented. The Housekeeping Manager confirmed that no special cleaning requests were made for the resident's room. The failure to follow the facility's scabies management policy and ensure proper medication administration led to the deficiency in infection control practices.
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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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