St Annes Nursing Center, St Annes Residence Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Miami, Florida.
- Location
- 11855 Quail Roost Drive, Miami, Florida 33177
- CMS Provider Number
- 105560
- Inspections on file
- 25
- Latest survey
- November 13, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at St Annes Nursing Center, St Annes Residence Inc during CMS and state inspections, most recent first.
Two residents with complex medical histories experienced falls and changes in condition, but their care plans remained generic and unchanged, lacking individualized interventions despite facility policy requiring tailored, measurable plans. Staff interviews confirmed that specific interventions were not implemented after falls, and care plans did not address unique needs such as communication barriers or evolving clinical status.
Two residents experienced lapses in supervision and improper use of fall prevention devices during personal care, resulting in one resident falling from bed and sustaining a head injury while on anticoagulant therapy, and another being left at risk of falling due to staff not properly using bed wedges. Staffing shortages and lack of timely intervention updates contributed to these deficiencies.
The facility failed to follow physician orders for two residents requiring floor mats and one resident needing oxygen at a specific rate. A resident was observed with only one floor mat instead of two, and another had a mat improperly placed, both contrary to orders. Additionally, a resident receiving hospice care was given oxygen at 1.25 liters per minute instead of the prescribed 2.0 liters per minute. These deficiencies highlight lapses in adhering to prescribed safety and care protocols.
A resident was incorrectly coded in the MDS as being discharged to a hospital instead of an Assisted Living Facility. The error was identified through a review of clinical records and discharge assessments, which showed a discrepancy between the MDS coding and the nurse's notes. The MDS Coordinator acknowledged the mistake, citing a lapse in the verification process between the Social Services and MDS departments.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in care. One resident had inadequate floor mat interventions, resulting in falls. Another resident also lacked proper floor mat placement, increasing fall risk. A third resident received oxygen at a lower rate than prescribed, causing low oxygen saturation. Staff communication and adherence to care plans were insufficient.
A resident's drainage bag was improperly placed above the side rail, increasing the risk of dislodgement. An RN Supervisor confirmed the bag should be lower than the resident to ensure proper flow. The resident had a diagnosis of hyperplasia with lower tract symptoms and was at increased risk due to retention. The facility's policy required the drainage bag to be positioned lower to allow gravity drainage, but this was not followed.
A resident was discharged to an Assisted Living Facility, but the MDS was incorrectly coded to indicate a discharge to a Short-Term General Hospital. The error was acknowledged by the MDS Coordinator, who explained that the Social Services department inputs discharge information, while the MDS department verifies it. The facility's policy requires accurate and ongoing assessments, which was not adhered to in this case.
A facility failed to accurately complete a Level I PASRR for a resident, as the documentation did not include any diagnosis despite the resident's history of mental illness. The PASRR screen decision-making section was left unchecked, which was inconsistent with the resident's medication records and evaluation notes. Interviews with staff revealed discrepancies in the PASRR documentation, and the failure to initiate a new resident review earlier was a critical oversight.
Surveyors found that the facility did not consistently develop or implement care plans for two residents requiring bilateral floor mats for fall prevention, as only one mat was in place and care plans lacked the required intervention. Additionally, a resident receiving oxygen therapy was observed with a flow rate below the physician's order, and staff failed to verify the correct rate during rounds, resulting in low oxygen saturation until corrected.
A resident with an indwelling urinary catheter was found with the drainage bag positioned above the bladder level, contrary to facility policy and standard infection prevention practices. Nursing staff and the DON confirmed that the drainage bag should be kept below the bladder to prevent backflow and infection, but this protocol was not followed for a resident with BPH, obstructive uropathy, and a pressure ulcer.
A resident with severe cognitive impairment and end-stage cardiac disease was observed receiving oxygen at 1.25 L/min instead of the prescribed 2 L/min via nasal cannula. Staff failed to verify and adjust the oxygen flow rate as ordered, resulting in a critically low oxygen saturation. Facility policy required staff to ensure the prescribed oxygen rate, but this was not followed.
A QAA committee failed to correct a recurring infection control deficiency when a resident's respiratory equipment, including a nebulizer and tubing, was found stored uncovered on a bedside table next to a live plant. Despite regular interdisciplinary meetings and established policies, the same issue was observed again, showing ineffective resolution of the previously cited problem.
Staff did not follow infection control protocols for storing respiratory devices and cleaning shared blood pressure cuffs between residents. An incentive spirometer was left uncovered on a resident's nightstand, and a nurse used the same blood pressure cuff on multiple residents without disinfecting it, contrary to facility policy and expectations.
The facility failed to maintain its automatic sprinkler system according to NFPA 101 standards. During a survey, it was found that several sprinklers were covered by foreign material, corroded, or damaged, particularly in the kitchen and main entrance. Additionally, there was a lack of a spare dry sprinkler for the freezer in the mechanical room. These issues were acknowledged by the Maintenance Director and discussed with the Administrator.
The facility failed to document one of the required quarterly fire drills for the third quarter on the second shift in 2024, as per NFPA 101 standards. This deficiency was identified during a records review with the Maintenance Director, who acknowledged the missing documentation. The issue was also discussed with the Administrator during the exit conference.
During a Life Safety Survey, an unsecured oxygen cylinder was found in the Dialysis Room of the facility. The cylinder was in use by a resident, and the deficiency was acknowledged by both the Maintenance Director and the Administrator. This incident highlights a failure to comply with NFPA 101 standards for gas equipment storage.
Failure to Individualize Resident Care Plans Following Falls
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for two residents, as evidenced by care plans that contained generic interventions not tailored to each resident's specific health needs and functional status. For one resident with dementia and impaired mobility, the care plan remained largely unchanged over multiple quarterly reviews, despite several documented falls, including incidents resulting in a skin tear and a hematoma that required hospitalization. The interventions listed were broad and not specific to the resident's evolving condition, and there was no evidence of new or revised interventions following significant events such as falls. Another resident with Alzheimer's disease, COPD, and diabetes also had a care plan that did not reflect individualized interventions, even after experiencing a fall. The care plan problems and interventions remained static over an extended period, with only minor updates that did not address the resident's changing clinical status or specific needs. Observations indicated the resident was confused and communicated in both English and Spanish, but the care plan did not address these unique communication needs or other individualized factors. Interviews with facility staff, including the Care Plan Coordinator and the resident's physician, revealed a lack of awareness and implementation of specific interventions following falls. The Care Plan Coordinator was unable to identify what interventions were implemented after documented falls, and the physician confirmed that expected fall precautions were not put in place after the initial incident. The facility's policy requires individualized, measurable care plans based on assessment findings, but this was not followed for the residents in question.
Failure to Provide Adequate Supervision and Fall Prevention Measures
Penalty
Summary
The facility failed to provide adequate supervision and implement safety measures for two residents, resulting in accident hazards and increased risk of injury. One resident with severe cognitive impairment and a history of falls experienced a fall from bed during personal care. The CNA providing care left the resident unattended on the bed while changing gloves, during which time the resident rolled off the bed and sustained a head injury with a large hematoma and bleeding. The resident was on anticoagulant therapy, which was not communicated to emergency services by facility staff. Prior to this incident, the resident had a previous fall with injury, but no additional fall prevention interventions were implemented until after the second fall. The care plan was not updated with appropriate interventions such as floor mats and bed wedges until after the injury occurred. Staff interviews revealed that the CNA assigned to the resident had limited experience, having only worked in the facility for a few months and often worked alone despite being assigned a high number of residents. The CNA reported difficulty working in pairs due to staffing levels, and on the night of the incident, each CNA was responsible for 14 residents. The DON and Risk Manager acknowledged that there was a gap in communication regarding the implementation of fall prevention interventions after the first fall, and that a physician's order was required for certain safety devices, which contributed to the delay in implementing these measures. In a separate incident, another resident was left at risk of falling during personal care when staff failed to properly use fall prevention devices. During morning care, one CNA left the room while the other continued care, leaving the resident near the edge of the bed with the side padding/wedge down. The CNA admitted to forgetting to raise the side wedge and not positioning the resident in the middle of the bed as required. The unit manager confirmed that staff should not have left the side wedge down and should have called for help if needed. Both incidents demonstrate a failure to maintain an environment free from accident hazards and to provide adequate supervision and use of assistive devices as required by facility policy.
Failure to Follow Physician Orders for Safety Equipment and Oxygen Administration
Penalty
Summary
The facility failed to adhere to physician orders for two residents who required floor mats for safety. Resident #25 was observed in bed with only one floor mat on the left side, despite having a physician's order for two floor mats to be placed on each side of the bed. The RN Supervisor confirmed the need for two mats but was unable to locate the second mat in the room. A CNA assigned to Resident #25 acknowledged that the resident usually only had one mat in place, which contradicts the physician's order. This oversight is significant given Resident #25's history of being found on the floor, indicating a potential risk of falls. Similarly, Resident #52 was observed with one floor mat in place on the right side of the bed, while the other mat was folded and leaning against the nightstand. This setup did not comply with the physician's order for floor mats to be used when the resident is in bed. The CNA present during the observation did not provide an explanation for the improper placement of the floor mats, which could compromise the resident's safety, especially considering their severe dependency for Activities of Daily Living (ADL). Additionally, the facility did not follow the physician's order for Resident #95, who was receiving hospice care and required humidified oxygen at a continuous rate of 2.0 liters per minute. Instead, the oxygen was observed to be administered at 1.25 liters per minute. The Director of Nursing confirmed that the oxygen should be delivered at the prescribed rate, whether continuous or as needed. This discrepancy in oxygen administration could have implications for the resident's health, given their severe dependency on ADLs and altered mental status.
Plan Of Correction
Immediate Action: Resident sample # 25- care plan was reviewed and revised to include implementation of floor mats per physician orders by the MDS Nurse. Resident sample # 52 floor mat was placed as per physician orders. The Nurse and CNA were educated by the Nurse Manager on expectation of following physician orders and/or implementing the identified appropriate care plan interventions for floor mats. Resident sample #95 The was increased from 1.25 liters per minute to 2 Liters per minute as per physician orders. saturation was checked and was reported to the Hospice team. The Nurse was educated by the Nurse Manager on expectation of following physician orders and/or implementing the identified appropriate care plan interventions for use. Identification of Residents with potential to be affected: All residents in the facility have the potential to be affected. Interdisciplinary review and verification of care plan interventions and orders for floor mats and use. System Changes: The facility Prevention Policy and Medication Administration Policy were reviewed for accuracy. Nurses and CNAs were educated and trained on the Falling Star Program and use of floor mats and resident use as indicated in the physician orders by the Director of Nursing and Risk Manager. Licensed nursing staff are to verify and document in the Treatment Administration Record the use of floor mats and orders for use every shift. Licensed nursing staff were educated by the Director of Nursing and the Assistant Director of Nursing on medication administration with emphasis on right dosage for use. Monitoring: Surveillance Rounds by Nurse Manager/designee to audit for compliance the residents with orders for floor mats and residents with use 3x a week for 90 days. The results of the rounds will be reported to the monthly Quality Assurance Performance Improvement Committee. Responsible Party: Unit Managers, Supervisor, Risk Manager, ADON and DON.
MDS Coding Error for Resident Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, resulting in a discrepancy in the discharge information. The resident, who was initially admitted from a Short-Term General Hospital with a medical diagnosis of other specified injuries, was scheduled to be discharged to an Assisted Living Facility (ALF). However, the MDS was incorrectly coded to indicate that the resident was discharged to a Short-Term General Hospital instead of the ALF. The error was identified during a review of the resident's clinical records and discharge assessment. The discharge assessment MDS reference indicated a planned discharge, but the section for discharge status incorrectly coded the resident as being discharged to a hospital. This was contrary to the nurse's notes, which documented that the resident was discharged to the ALF and transported via wheelchair. During an interview, the MDS Coordinator acknowledged the error, explaining that the Social Services department is responsible for inputting discharge information, while the MDS department verifies the timely submission of this information. The coordinator accepted responsibility for the error on behalf of the department. The facility's policy requires a complete admission observation/assessment to develop a care plan tailored to the resident's needs, with ongoing assessments throughout the resident's stay.
Plan Of Correction
Immediate Action: The Minimal Data Set dated for sample resident #200 was modified for discharge status to an Assisted Living Facility in section A 2105 on was resubmitted on. Responsible staff member was re-educated on accurate Minimal Data Set completion by the MDS Nurse. Identification of Residents with potential to be affected: All residents that are discharged have the potential to be affected. The discharge assessment- return not and return MDSS completed since will be audited for discharge location accuracy and modified per Resident Assessment Instrument Manual. Inaccuracies identified will be corrected and resubmitted. System Changes: All resident discharges will be discussed by the Interdisciplinary Team on the next business day to determine discharge disposition. Discharges will be completed by the MDS Nurses in the entirety as of. Monitoring: Monthly audits of all Discharge Assessments will be audited weekly for accuracy for the next 3 months. An audit sheet will be maintained to demonstrate accurate completion of section A2105. Results will be reported monthly to the Quality Assurance Performance Improvement committee. At the end of 3 months, the Quality Assurance Performance Improvement Committee will reassess the need for ongoing audit frequency and duration. Responsible Party: MDS Nurses/ Coordinators
Deficiencies in Care Planning and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in their care. Resident #25 was observed with only one floor mat in place, despite a physician's order for two mats to prevent falls. The care plan for this resident did not include interventions for floor mats, and staff were unaware of the correct protocol, resulting in the resident being found on the floor multiple times. Resident #52 was also affected by inadequate care planning, as they were observed with only one floor mat in place, contrary to the prescribed two mats. The staff failed to communicate effectively about the required interventions, and the resident was found on the floor on several occasions. The care plan for this resident did not adequately address the need for floor mats, contributing to the risk of falls. Resident #95 experienced a deficiency in care related to the administration of oxygen. The resident was observed receiving oxygen at a rate lower than the physician's order, which led to a dangerously low oxygen saturation level. The staff did not verify the oxygen delivery rate during rounds, resulting in a delay in adjusting the oxygen to the prescribed level. This oversight in care planning and execution posed a significant risk to the resident's health.
Plan Of Correction
Immediate Action: Resident sample #25 - care plan was reviewed and revised to include implementation of floor mats per physician orders by the MDS Nurse. Resident sample #52 - floor mat was placed as per physician orders and care plan. The Nurse and CNA were educated by the Nurse Manager on the expectation of following physician orders and/or implementing the identified appropriate care plan interventions for floor mats. Resident sample #95 - the flow rate was increased from 1.25 liters per minute to 2 liters per minute as per physician orders and care plan. Saturation was checked and reported to the Hospice team. The Nurse was educated by the Nurse Manager on the expectation of following physician orders and/or implementing the identified appropriate care plan interventions for use. Identification of Residents with potential to be affected: All residents in the facility have the potential to be affected. Interdisciplinary review and verification of care plan interventions and orders for floor mats and use. System Changes: The facility Prevention Policy and Medication Administration Policy were reviewed for accuracy. Nurses and CNAs were educated and trained on the Falling Star Program and use of floor mats and resident use as indicated in the physician orders and care plan by the Director of Nursing and Risk Manager. Licensed nursing staff are to verify and document in the Treatment Administration Record the use of floor mats and orders for use every shift. Licensed nursing staff were educated by the Director of Nursing and the Assistant Director of Nursing on medication.
Improper Placement of Drainage Bag in Resident's Care
Penalty
Summary
The facility failed to provide adequate and appropriate healthcare and treatment services for a resident, as evidenced by the improper placement of a drainage bag. During an observation, the drainage bag was found anchored to the side rail above the resident, increasing the risk of dislodgement. A Registered Nurse (RN) Supervisor confirmed that the drainage bag should be positioned lower than the resident to facilitate proper flow and prevent complications. The RN Supervisor adjusted the drainage bag to the correct position after being informed of the issue. The resident involved had a diagnosis that included hyperplasia with lower tract symptoms and was at increased risk due to retention. The care plan for the resident included maintaining the anchoring device to prevent dislodgement and monitoring the site for skin integrity. The facility's policy stated that the drainage bag should be kept as a closed system and positioned lower than the resident to allow drainage by gravity. Despite these guidelines, the improper placement of the drainage bag was observed, indicating a failure to adhere to established protocols.
Plan Of Correction
Immediate Action: Drainage bag for affected sample resident #184 was immediately repositioned below level of the to prevent. Care plan reviewed for accuracy. Identification of Residents with potential to be affected: All residents with using a drainage system, have potential to be affected. System Changes: Control Policy was reviewed for accuracy. All licensed Nursing staff were educated and trained by the Control Preventionist, Director of Nursing, and the Assistant Director of Nursing in care with emphasis on proper placement of Drainage appliance/bag. They were required to demonstrate return demonstration on proper placement on drainage appliance/bag. Monitoring:
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, resulting in a discrepancy between the recorded discharge location and the actual discharge destination. The resident, who was admitted from a Short-Term General Hospital with a medical diagnosis of other specified injuries, was scheduled to be discharged to an Assisted Living Facility (ALF). However, the MDS was incorrectly coded to indicate that the resident was discharged to a Short-Term General Hospital instead of the ALF. The error was identified during a review of the resident's clinical records and was confirmed by a nurse's note documenting the resident's discharge to the ALF. During an interview, the MDS Coordinator acknowledged the mistake, explaining that the Social Services department is responsible for inputting discharge information, while the MDS department verifies the information's timely submission. The coordinator accepted responsibility for the error on behalf of the department. The facility's policy requires ongoing and individualized assessments to meet residents' needs, but this process was not accurately followed in this instance.
Plan Of Correction
Immediate Action: The MDS Set dated for sample resident #200 was modified for discharge status to an Assisted Living Facility in section A 2105 on was resubmitted on. Responsible staff member was re-educated on accurate MDS completion by MDS Nurse. Identification of Residents with potential to be affected: All residents that are discharged have the potential to be affected. The discharge assessment- return not and return MDSS completed since, will be audited for discharge location accuracy and modified per Resident Assessment Instrument Manuel. Inaccuracies identified will be corrected and resubmitted. System Changes: All resident discharges will be discussed by the Interdisciplinary Team on the next business day to determine discharge disposition. Discharges will be completed by the MDS Nurses in the entirety as of. Monitoring: Monthly audits of all Discharge Assessments will be audited weekly for accuracy for the next 3 months. An audit sheet will be maintained to demonstrate accurate completion of section A2105. Results will be reported monthly to the Quality Assurance Performance Improvement Committee. At the end of 3 months, the Quality Assurance Performance Improvement Committee will reassess the need for ongoing audit frequency and duration. Responsible Party: MDS Nurses/ Coordinators
Failure to Accurately Complete PASRR for Resident
Penalty
Summary
The facility failed to accurately complete a Level I Preadmission Screening and Resident Review (PASRR) for a resident, identified as Resident #166, out of five residents investigated for Level I PASRR. The deficiency was identified during a survey when it was found that the PASRR documentation for Resident #166 did not include any diagnosis, despite the resident having a history of mental illness. The PASRR screen decision-making section did not have any diagnosis checked, which was a significant oversight given the resident's medical history. The record review revealed that Resident #166 had an admission date with unspecified diagnoses. The Minimum Data Set (MDS) indicated that the resident was not considered by the state level II PASRR process to have a serious mental illness or intellectual disability, which was inconsistent with the resident's medication records and evaluation notes. The resident was taking medications that suggested a history of mental illness, yet this was not reflected in the PASRR documentation. Interviews with facility staff, including the Social Services Director and the Director of Care Coordination, revealed that there were discrepancies in the PASRR documentation. The Social Services Director acknowledged the discrepancies and noted that a resident review was scheduled to occur within 30 days of the evaluation to assess any changes in the patient's condition. The Director of Care Coordination stated that significant changes in a resident's condition are typically evident through behavioral changes, and the facility reviews PASRRs within 30 days for further evaluation. However, the failure to initiate a new resident review for Resident #166 earlier to include all mental illness diagnoses was a critical oversight.
Plan Of Correction
Immediate Action: The Pre Admission Screening and Resident Review for sample resident #166 was reviewed, updated, and submitted to the appropriate state agency on . Confirmation of update and receipt of determination has been obtained and was filed in residents chart. The staff member responsible received a 1:1 education on procedure for completing the Pre Admission Screening and Resident Review by Corporate Director of Social Service. Identification of Residents with potential to be affected: All residents have the potential to be affected. System Changes: The PASRR Policy was reviewed with all Social Work Staff responsible for completing PASRR Level I and requirement. All newly admitted residents will have the Pre Admission Screening and Resident Review reviewed for accuracy and resubmitted when inaccuracies are identified. Monitoring: A Pre Admission Screening and Resident Review audit for all admissions and present residents are being reviewed by the Social Work Director to ensure accurate completion. The Audit results will be submitted to the monthly Quality Assurance Performance Improvement Team for review. The audit will continue for 90 days or until the committee agrees substantial compliance is achieved. Responsible Party: Director of Social Work Corporate Director of Social Work/ Care Coordinator
Failure to Implement and Document Required Fall and Respiratory Care Interventions
Penalty
Summary
The facility failed to develop and implement appropriate care plans for residents with specific needs, as evidenced by observations, interviews, and record reviews. For two residents with physician orders for bilateral floor mats to prevent falls, the care plans did not include interventions for floor mats, and the mats were not consistently in place as ordered. One resident was observed with only one floor mat in place when two were required, and staff interviews confirmed that the protocol was not consistently followed. Documentation showed a history of falls for these residents, and physician orders clearly specified the need for bilateral floor mats every shift, yet this intervention was omitted from the care plans and not reliably implemented in practice. Additionally, the facility failed to implement a respiratory care plan for a resident receiving oxygen therapy. The resident was observed receiving oxygen at a flow rate lower than the physician-ordered amount, and staff did not verify the oxygen flow rate during rounds. The resident's oxygen saturation was found to be critically low until the flow rate was corrected by staff. The care plan for this resident did include the need for oxygen therapy at the prescribed rate, but the intervention was not properly implemented, resulting in a deviation from the physician's order. These deficiencies were identified through direct observation, staff interviews, and review of medical records and care plans. The facility's own care planning policy requires individualized, interdisciplinary plans of care based on assessment findings and physician orders, but these requirements were not met for the residents in question, leading to lapses in the delivery of ordered interventions for fall prevention and respiratory care.
Improper Positioning of Urinary Catheter Drainage Bag
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was observed lying in bed with the catheter drainage bag anchored to the side rail above the resident's head, rather than below the level of the bladder. This placement was confirmed by a Registered Nurse (RN) Supervisor, who acknowledged that the drainage bag should be positioned lower than the bladder to facilitate proper urine flow. The RN Supervisor adjusted the drainage bag after the issue was pointed out. Interviews with nursing staff and the Director of Nursing confirmed that facility protocol and policy require the drainage bag to be kept below the bladder to prevent backflow and potential infection. The resident involved had a medical history including benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, obstructive uropathy, and a pressure ulcer. Physician orders and the care plan specified the need for indwelling catheter care every shift and interventions to prevent infection, including proper anchoring of the catheter. Facility policy also outlined the importance of maintaining the drainage bag below bladder level as part of infection prevention. The failure to position the drainage bag correctly constituted a lapse in following established protocols and care plans for catheter management.
Failure to Administer Oxygen at Prescribed Rate
Penalty
Summary
The facility failed to provide appropriate respiratory care consistent with professional standards of practice for a resident receiving oxygen therapy. Observations revealed that the resident, who had severe cognitive impairment and was dependent on ADLs, was receiving oxygen at 1.25 liters per minute via nasal cannula, despite a physician's order for 2 liters per minute. This discrepancy was observed on two separate occasions, and photographic evidence was obtained. The resident's care plan and physician's orders both specified the need for continuous oxygen at 2 liters per minute, but staff did not ensure the prescribed rate was being delivered. A registered nurse acknowledged not verifying the oxygen flow rate during morning rounds. The resident had a history of acute chronic diastolic congestive heart failure, nonrheumatic aortic valve stenosis, and was receiving hospice care. During the survey, the resident's oxygen saturation was found to be critically low at 76% while on the incorrect oxygen flow rate. The facility's policy required staff to set the oxygen concentrator to the prescribed flow rate, but this was not followed, resulting in the resident receiving less oxygen than ordered.
Repeated Infection Control Deficiency Due to Uncovered Respiratory Equipment
Penalty
Summary
The facility's Quality Assurance and Assessment (QAA) committee failed to implement an effective plan of action to correct a previously identified quality deficiency related to infection prevention and control. During a recertification survey, it was observed that respiratory equipment, specifically a nebulizer and tubing, was stored uncovered on a bedside table next to a live plant for one resident. This storage practice did not comply with infection control procedures and was previously cited as a deficiency under F 880-Infection Prevention & Control. The facility's records confirmed that the QAA committee met monthly and included a range of interdisciplinary team members, such as the Administrator, Medical Director, DON, ADON, Infection Control Preventionist, and others. Despite these regular meetings and the existence of policies aimed at monitoring and improving care quality, the same infection control issue was observed again, indicating that the committee did not effectively address or resolve the previously cited deficiency.
Failure to Implement Infection Control Practices for Respiratory Devices and Shared Equipment
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for three out of seven sampled residents. For one resident with a history of COPD, pulmonary embolism, and recent hospitalization for respiratory issues, an incentive spirometer was observed on the nightstand without a protective covering when not in use. The registered nurse confirmed that the device should be stored in a plastic bag and dated, but it was left uncovered to keep it readily available. The Director of Nursing also acknowledged that, although there was no formal protocol, the expectation was for the device to be bagged when not in use. Additionally, staff failed to disinfect the blood pressure cuff on the vital signs machine between use on different residents. One resident had their blood pressure measured with a cuff that was not cleaned before or after use, and the same cuff was subsequently used on another resident without disinfection. The registered nurse did not use disinfectant wipes, which were not present on the machine, and admitted to not cleaning the cuff due to nervousness. The Director of Nursing stated that staff are expected to clean the vitals machine with bleach wipes between residents, as outlined in the facility's infection control policy.
Deficiency in Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 101 standards, as observed during a Life Safety Survey tour. During the inspection, it was noted that several sprinklers in different areas of the facility were either covered by foreign material, corroded, or damaged. Specifically, in the kitchen, 8 out of 28 sprinklers were found to be in such a condition. Additionally, at the main entrance on the first floor, 2 out of 3 sprinklers were similarly affected. Further deficiencies were observed in the first-floor mechanical room across from the chapel, where there was a lack of a spare dry sprinkler for the freezer, and no means to restore service was available. These issues were acknowledged by the Maintenance Director during the survey and were also discussed with the Administrator during the exit conference. The report highlights that the facility did not adhere to the required standards for the inspection, testing, and maintenance of its water-based fire protection systems as outlined in NFPA 25. The lack of proper maintenance and availability of necessary equipment could potentially compromise the safety and effectiveness of the sprinkler system in the event of a fire.
Plan Of Correction
5/16/25 Immediate Action: A Certified Fire Protection contractor completed an inspection of the building on 4/8/2025. The proposal was signed April 30, 2025 to replace corroded and damaged sprinklers. The contract company is pending material availability which includes spare dry sprinkler for freezer. Identification of Residents with potential to be affected: All in-house residents have the potential to be affected. System Changes: The facility reviewed the preventive maintenance program to include a visual inspection of sprinkler heads is conducted monthly. Maintenance staff were retrained / educated on identifying signs of corrosion and damage to the sprinkler heads during the visual inspections. Monitoring: Director of Maintenance / designee will maintain a log of inspections and report will be present in the monthly Quality Assurance Performance Improvement committee meeting. Responsible Party: Director of Maintenance 5/16/25 Immediate Action: A Certified Fire Protection contractor completed an inspection of the building on 4/8/2025. The proposal was signed April 30, 2025 to replace corroded and damaged sprinklers. The contract company is pending material availability which includes spare dry sprinkler for freezer. Identification of Residents with potential to be affected: All in-house residents have the potential to be affected. System Changes: The facility reviewed the preventive maintenance program to include a visual inspection of sprinkler heads is conducted monthly. Maintenance staff were retrained / educated on identifying signs of corrosion and damage to the sprinkler heads during the visual inspections. Monitoring: Director of Maintenance / designee will maintain a log of inspections and report will be present in the monthly Quality Assurance Performance Improvement committee meeting. Responsible Party: Director of Maintenance
Failure to Document Quarterly Fire Drill
Penalty
Summary
The facility failed to perform fire drills in accordance with NFPA 101 standards, as evidenced by a lack of documentation for one of the four required fire drills in 2024. Specifically, the missing documentation pertained to the fire drill that was supposed to be conducted during the third quarter on the second shift. This deficiency was identified during a records review process conducted between noon on April 7, 2025, and 5:00 pm on April 8, 2025, with the Maintenance Director present. During the staff interview conducted within the same timeframe, the Maintenance Director acknowledged the absence of documentation for the fire drill. This finding was also discussed and acknowledged by the Administrator during the exit conference. The report highlights that the facility did not meet the requirement of conducting fire drills at least quarterly on each shift, as mandated by NFPA 101.
Plan Of Correction
5/16/25 Immediate Action: A fire drill was conducted on the missed shift on May 9, 2025 to ensure that staff on the second shift are trained and prepared for emergency situations. Identification of Residents with potential to be affected: All in-house residents have the potential to be affected. System Changes: A fire drill schedule/calendar was created for the entire year which clearly indicates the required monthly drill shift. Monitoring: The Director of Maintenance will ensure the facility documentation is accurate regarding the scheduled shift. The schedule/calendar will be submitted to the monthly Quality Assurance Performance Improvement committee meeting. Responsible Party: The Director of Maintenance
Unsecured Oxygen Cylinder in Dialysis Room
Penalty
Summary
The facility failed to maintain gas equipment-cylinder and container storage in accordance with NFPA 101 standards. During a Life Safety Survey tour conducted between 11:00 am and 4:30 pm on April 8, 2025, an unsecured oxygen cylinder was observed in the Dialysis Room. This cylinder was in use by a resident at the time of the survey. The unsecured state of the cylinder was noted as a deficiency in the facility's adherence to safety regulations. The survey was conducted with the Maintenance Director, who acknowledged the finding during the tour. The unsecured oxygen cylinder was identified at 2:06 pm, highlighting a lapse in the facility's protocol for securing gas equipment. The observation was made in the presence of the Maintenance Director, ensuring that the deficiency was recognized by the facility's staff. The deficiency was further discussed and acknowledged by the Administrator during the exit conference. The report cites specific sections of the NFPA 101 and NFPA 99 standards that were not met, emphasizing the importance of proper storage and handling of gas equipment to ensure safety within the facility. The failure to secure the oxygen cylinder represents a breach in compliance with these safety standards.
Plan Of Correction
Responsible Party: The Director of Maintenance Immediate Action: Oxygen cylinder was secured upon identification. A facility wide audit was conducted to identify unsecured cylinder holders. Identification of Residents with potential to be affected: All in-house residents have potential to be affected. System Changes: All oxygen cylinder holders without a safety mechanism were removed from circulation. The safety mechanism was installed on those holders. Education for oxygen cylinder safety training was conducted with licensed staff. Upon identification of unsure holder, they must remove the holder from circulation and report to the Maintenance Department via Worx hub. Monitoring: Daily audits of all oxygen cylinder holders in storage areas to ensure all oxygen cylinder holders are secure prior to use. Results of the daily audit will be reported to Monthly Quality Assurance Performance Improvement Committee meeting for the next 90 days or until the committee agrees substantial compliance is met. Responsible Party: Director of Maintenance or designee
Latest citations in Florida
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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