Titusville Rehabilitation & Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Titusville, Florida.
- Location
- 1705 Jess Parrish Ct, Titusville, Florida 32796
- CMS Provider Number
- 105448
- Inspections on file
- 25
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Titusville Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
The facility failed to ensure its QAA/QAPI committee sustained prior improvement measures related to complete and accurate medical records. The same F842 deficiency was cited again after a prior recertification survey, and the repeat citation was attributed to insufficient auditing and oversight. The Administrator stated the QAPI committee met monthly and reviewed clinical metrics, care issues, grievances, and concierge round concerns, but multiple providers still documented on paper, which he felt contributed to records not being complete and accurate.
Pressure ulcer care, wound treatment, and care plan failures: Two residents had deficiencies involving pressure injury management. One resident with severe cognitive impairment, total ADL dependence, diabetes, and a PEG tube developed facility-acquired pressure ulcers while turning/repositioning and skin checks were frequently undocumented, the care plan was not revised after wound changes, and ordered sacral treatment was not documented as performed. Another resident admitted with sepsis, necrotizing fasciitis, paraplegia, and stage 4 pressure injuries had delayed wound vac changes, inconsistent skin assessments, and missing documentation for ordered wound treatments.
Food storage, sanitation, and hot holding practices were deficient. The walk-in refrigerator had food debris and residue, spice bins were dirty, the dry storage room was 76 degrees F with a broken AC unit and expired granola bars, and staff were observed with improper hair/beard covering. During lunch service, potentially hazardous foods on the steam table were below the required 135 degrees F, including sloppy joe, pureed cabbage, and mashed potatoes, and a cook reached into food with ungloved fingers after dropping part of an alcohol wipe into the mashed potatoes.
A resident with a BIMS of 13/15, a hx of TBI, and dependence for all ADLs said she was unhappy, did not feel she belonged, and wanted a transfer to be closer to family. She also preferred to be outside more often, but the facility only allowed residents to leave the building if they smoked. The resident's record lacked documentation of attempts to find alternate placement, and the Administrator could not provide copies of referrals while the SSD said referrals had been sent to nearby facilities.
A resident with bipolar disorder, morbid obesity, and muscle wasting was documented as blind or severely visually impaired, yet her care plan had no interventions for vision loss. The hospital transfer form, MDS, nurse note, and SSD notes all reflected significant vision impairment and a pending cataract surgery issue, but staff confirmed the impairment was not included in the care plan and that the resident signed paperwork without family being called to explain it.
A resident with diabetes, malnutrition, heart disease, and skin cancer had forehead and scalp dressings after outpatient lesion removal, but the facility did not include wound monitoring or care in the comprehensive care plan. The active orders and MARs/TARs did not address the head wounds, and the MDS Coordinator and DON confirmed the IDT care plan had not been revised to reflect the resident’s wound needs.
Failure to assess and treat resident skin impairments. A resident with CVA, flaccid hemiplegia, and bladder dysfunction had orders for Bacitracin to buttock excoriation every shift and was identified as at risk for wounds. The resident reported a worsening right thigh area that had not been assessed, while observation showed bright red drainage on the buttock and a large reddened area on the right upper thigh. Staff documentation was incomplete, an LPN could not locate the ordered Bacitracin, and an UM admitted signing the TAR without providing the treatment.
Failure to Monitor Supplemental Oxygen Therapy: A resident with respiratory failure, COPD, pneumonia, and moderate cognitive impairment was observed receiving continuous O2 by nasal cannula, but the MAR had no physician order for supplemental O2 and no directions to monitor O2 sats. The RN did not recall checking the resident’s O2 status during the shift, and the record showed O2 saturation checks had not been documented for more than six weeks.
A resident with diabetes, malnutrition, heart disease, and skin cancer had forehead and scalp dressings after an outpatient dermatology procedure, but the chart lacked the dermatologist's notes, wound care instructions, and monitoring orders. The resident was observed with undated dressings that staff had not checked, while the RN consultant and DON confirmed the medical record was missing the outpatient records and related documentation.
Surveyors found that the facility failed to maintain a homelike environment on two units, with multiple areas showing chipped paint, broken sheetrock, missing baseboards, holes in walls, and missing tiles. The Maintenance Director reported daily rounds and a reporting system for repairs, but some issues had been awaiting repair for an undetermined period. The Administrator acknowledged the need for repairs to meet resident environment standards.
Two residents did not receive care in accordance with physician orders and professional standards. One resident with hypertension did not have blood pressure monitored or documented as required before administration of antihypertensive medications, and the care plan for cardiovascular issues was delayed. Another resident with symptoms of a UTI experienced a delay in urine specimen collection for ordered diagnostic testing, with no documentation explaining the delay and inconsistent staff communication.
A resident with complex medical needs was documented as receiving Midodrine outside of physician-ordered blood pressure parameters on multiple occasions, with several nurses recording the medication as given despite orders to hold it. The MAR showed repeated documentation errors, and staff interviews confirmed that the medication was not always administered as recorded, nor were proper documentation codes used.
A resident with a Full Code status experienced a delay in CPR initiation due to confusion over contradictory DNR and Full Code orders. The resident was found unresponsive, and the LPN initially followed a hospice chart indicating DNR, leading to a delay in CPR until the code status was confirmed. Discrepancies in the timeline of events were noted, highlighting the facility's failure to promptly verify and act on the resident's code status.
A resident on hospice care was found unresponsive, and due to confusion over their code status, there was a delay in initiating CPR. The LPN initially believed the resident was a DNR based on incorrect hospice information, leading to a delay in CPR and calling 911. The facility's investigation was incomplete, failing to obtain timely staff statements and not reporting the incident to the State Survey Agency.
The facility did not provide a private setting for Resident Council meetings, holding them in an open area near the nurse's station, which led to residents fearing retaliation if they voiced complaints. During a meeting, 20 residents indicated they were afraid to complain about their care, and a review of council minutes showed few concerns were raised, suggesting underreporting due to fear.
The facility did not adequately address Resident Council concerns from June 2023 to June 2024, despite assurances from a new Administrator. The Activity Director, working alone and unaware of unresolved issues, communicated concerns to relevant departments but only received verbal resolutions. The lack of volunteers and the Director's hospitalization also led to a lack of activities, contributing to the Council's grievances.
Facility staff failed to inform residents of their rights, as revealed during a Resident Group meeting and review of Resident Council minutes. Residents and family members reported not receiving information about their rights upon admission or during their stay, and the Resident Council President confirmed that rights were not reviewed in meetings. The Activity Director, responsible for facilitating these meetings, could not provide documentation that resident rights had been reviewed or distributed.
The facility failed to provide a comprehensive activity program for its residents, resulting in a lack of engagement for three residents. One resident was left in bed without activities, another with severe cognitive impairment was not engaged, and a third expressed dissatisfaction with the lack of activities. The Activity Director struggled to manage alone, with no documentation of activities or one-to-one visits.
The facility failed to provide sufficient nursing staff, resulting in delayed medication administration for residents. Nurses were overwhelmed with high resident assignments and shared medication carts, causing significant delays in administering scheduled medications. Despite raising concerns, management did not provide feedback or solutions to address the staffing issues.
The facility failed to administer scheduled medications within the prescribed time for 31 residents due to staffing issues, leading to significant delays. Nurses were on split assignments, sharing medication carts, which caused delays in administering medications for conditions such as high blood pressure, pain, and depression. The facility's policy required medications to be given within one hour of the scheduled time, a guideline that was not followed. The DON acknowledged the issue, and the Medical Director discouraged splitting nurse assignments.
The facility was cited for a repeat deficiency in reporting due to insufficient auditing and oversight by the QAA/QAPI committee. The QAPI Plan required PIP subcommittees to identify improvement areas and report to the QAA Committee, but the facility failed to sustain prior improvements. The Administrator, new to the facility, could not confirm ongoing audits for past citations, acknowledging the system's failure.
The facility failed to update PASARR evaluations for two residents with newly diagnosed mental disorders. One resident, initially admitted with various conditions, was later diagnosed with schizophrenia, anxiety, and depressive disorders, but did not receive an updated PASARR. Another resident, admitted with bipolar disorder, received a new diagnosis of major depressive disorder, yet the PASARR was not updated. The DON and Interim DON acknowledged these oversights.
A resident was admitted with a diagnosis of schizophrenia, but the Level 1 PASARR evaluation completed by the hospital omitted this diagnosis. The interim Administrator and Social Service Director had differing views on responsibility for PASARR accuracy, while the Interim DON acknowledged the oversight and confirmed it was her responsibility to ensure accurate evaluations.
The facility failed to document education, consent, or contraindication for influenza and pneumococcal vaccines for four residents. Despite receiving vaccines, necessary records were missing, contrary to the facility's policy requiring documentation of consent, education, and prior vaccine administration.
A facility failed to maintain accurate medical records and medication administration. A resident's change in condition was not properly documented, with discrepancies in the timing of events and actions taken. Another resident did not receive prescribed eye drops as scheduled, and an LPN prematurely documented the administration. The DON acknowledged these practices were against policy, leading to deficiencies in care.
QAPI Oversight Failed to Sustain Prior Medical Record Improvements
Penalty
Summary
The facility failed to ensure its QAA/QAPI committee conducted performance improvement activities to verify that prior improvement measures were sustained. The report states the facility had previously been cited at F842 for incomplete and inaccurate medical records during the prior recertification survey, and during the current survey it was again found out of compliance with F842. The repeat deficiency was linked to insufficient auditing and oversight to prevent the citation. The Administrator stated the QAPI committee met monthly and reviewed floor rounds, clinical metrics, care issues, grievances, and concerns raised during concierge rounds, and that performance improvement plans were created when issues were identified. He acknowledged the repeat citation and stated that multiple providers still documented on paper, which he felt contributed to medical records not being complete and accurate.
Pressure ulcer care, wound treatment, and care plan failures
Penalty
Summary
The facility failed to provide care and services to maintain the highest practicable physical well-being by not preventing a facility-acquired pressure ulcer, not revising the pressure ulcer care plan after the resident’s wound status changed, and not implementing physician orders for existing pressure ulcers for two residents reviewed for pressure ulcers. One resident was admitted with chronic respiratory failure, a PEG tube, type 2 diabetes, and brain damage from low oxygen, and the admission MDS showed severe cognitive impairment, total dependence for ADLs, and risk for pressure injuries with preventive interventions in place. The care plan identified the resident as at risk for wounds and included turning/repositioning and heel floating, but the TAR showed frequent missing documentation for turning, repositioning, and skin observations across all shifts. For that resident, weekly skin checks later documented new skin impairment, and nursing progress notes identified in-house acquired pressure ulcers including stage 3 wounds to the buttock areas and stage 2 wounds to the sacrum and right buttock. Physician orders were entered for sacral wound treatment, but the TAR showed no documentation that the ordered sacral treatment was performed for several days after the order start date and again on another date. During observations, the resident was repeatedly found lying flat in bed with the head of bed slightly elevated, heels resting on the mattress, and at times exposed with bedding off to the side. Staff interviews confirmed the resident should have been repositioned every two hours, that skin observations were expected each shift, and that the care plan had not been revised to reflect the current wound status. The second resident was admitted with sepsis, necrotizing fasciitis, paraplegia, polyneuropathy, a stage 4 pressure ulcer of the right buttock, and an unstageable pressure ulcer. Hospital paperwork showed the resident had been admitted with a worsening decubitus ulcer that resulted in sepsis, and discharge paperwork included negative pressure wound therapy ordered for the stage 4 right gluteal wound three times weekly. The facility’s TAR did not document the wound vacuum being changed until nine days after admission. Weekly skin checks were inconsistent and listed multiple wound locations without staging or measurements, and the DON acknowledged the assessments did not consistently match the locations, descriptions, and staging of the skin issues. Additional skin evaluations listed wounds as present on admission that had not been documented earlier in the admission assessment, and treatment orders for several wounds had no documentation of being performed on some scheduled dates.
Food Storage, Sanitation, and Hot Holding Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards. During the kitchen tour, the walk-in refrigerator had visible food debris and residue along the baseboards and corners, and two spice bins in the food preparation area had sticky residue and debris in the bottom of the containers. In the dry storage room, the air conditioning unit had its cover off, debris and rust were visible on top of the unit, the room temperature was 76 degrees F, and a bin of granola bars was found past expiration. A dietary aide was also observed with a beard covering that did not fully cover the beard, and the Registered Dietitian was observed with hair net placement that did not cover the front of the hair. During lunch tray line observation, potentially hazardous foods on the steam table were held below the required hot holding temperature of 135 degrees F or greater. The observed temperatures were sloppy joe at 120 degrees F, pureed cabbage at 85 degrees F, and mashed potatoes at 132 degrees F. While checking temperatures, the cook dropped part of an alcohol wipe into the mashed potatoes and reached into the food with ungloved fingers to remove it. Additional observations included rust on wheels of equipment in the food preparation area, and a shelf with three frying pans lying with handles down and debris and food particles next to them. A male dietary aide was also observed handling plates with food without gloves.
Failure to Honor Resident Self-Determination and Transfer Preferences
Penalty
Summary
The facility failed to honor resident rights related to self-determination for one resident who was reviewed for choices. The resident stated she was unhappy at the facility, did not feel like she belonged, and had requested a transfer. She also said she preferred to be outside as much as possible, but the facility only allowed residents to exit the building if they smoked. The resident's quarterly MDS showed a BIMS score of 13/15, indicating she was mostly cognitively intact, and that she was dependent on staff for all ADLs and unable to move from the waist down. The assessment also noted a history of traumatic brain injury, and that she was able to use the internet, hold a conversation, and recall events. The resident had previously sought help from Social Services to move to a skilled nursing facility in a nearby city to be closer to family, and her care plan included a goal to adjust to LTC placement with an intervention for referral to a local contact agency as needed. The Social Services Director stated that several referrals were sent, but the resident was not accepted to facilities in the nearby cities she wanted. The Administrator could not provide copies of referrals, and there were no notes in the medical record showing attempts to find alternate placement per the resident's request. The Social Services Director later stated there were no long-term beds available at one nearby facility and that referrals had been faxed to other nearby facilities, while the DON stated she and the Social Worker were supposed to meet with residents who preferred to move from the facility to assess their needs in a care meeting.
Failure to Care Plan for Blindness and Visual Impairment
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident admitted with bipolar disorder, morbid obesity, and muscle wasting who was also documented as blind or severely visually impaired. The hospital transfer form indicated the resident was blind, the MDS assessment showed severely impaired vision with cognitive intactness and moderate assistance needs, and a nurse progress note documented that the resident was legally blind. Despite these findings, the resident’s care plan contained no interventions related to blindness or impaired vision. The record also showed that Social Services was aware the resident could not see, including a note that cataract surgery needed to be rescheduled and another note that the resident requested help accessing her funds. During interviews, the SSD stated that trouble seeing should be noted in the care plan and that an eye doctor should see the resident, and the DON stated that residents who were blind or visually impaired should have that reflected in their care plan. The Business Office Manager confirmed the resident signed paperwork without the family being called to explain it, and the MDS Coordinator confirmed there was no care plan for the resident’s visual impairment.
Care plan not updated for head wound care
Penalty
Summary
The facility failed to revise the comprehensive care plan to include wound management for a resident with non-pressure related skin conditions. Resident #36, an older female with diagnoses including type 2 diabetes mellitus, adult failure to thrive, malnutrition, heart disease, muscle wasting and atrophy of multiple sites, and left lateral forehead squamous cell carcinoma, was re-admitted to the facility after an acute care hospital stay. The most recent MDS quarterly assessment documented intact cognition and indicated no surgical wounds or wound care during the look-back period. On observation, the resident was found eating breakfast while lying in bed with one small and one large undated bordered adhesive gauze dressing with peeling edges on her forehead and scalp. She stated the dressings had been applied about one week earlier after skin cancer lesions were removed at the dermatologist’s office, and facility nurses had not looked at them since then. The active physician’s orders and MARs/TARs did not include monitoring of the head wounds, and the care plan did not include wound monitoring or care. The MDS Coordinator and DON both confirmed the care plan had not been revised to include the wounds, despite routine IDT and clinical meetings where updates were discussed.
Failure to Assess and Treat Resident Skin Impairments
Penalty
Summary
The facility failed to provide appropriate care consistent with professional standards of practice and failed to provide treatment to promote healing of a resident’s skin condition. The resident was admitted with diagnoses including cerebral infarction, flaccid hemiplegia affecting the dominant right side, and bladder dysfunction. The annual MDS indicated the resident was cognitively intact and at risk for pressure ulcers, with treatments including ointments or medications other than to the feet. Physician orders directed staff to apply Bacitracin to buttock excoriation every shift, and the care plan identified risk for wounds related to impaired mobility, bowel and bladder incontinence, fragile skin, and right-sided hemiplegia. The resident stated she believed there was a wound on her right thigh that no one had looked at and said she was afraid it might be getting worse. She later reported that no nurse had followed up or assessed her right thigh skin. Weekly skin assessments for February documented no new skin impairment on two occasions, and one assessment documented no new skin impairment while also listing redness to the buttock. During observation, the sacral area was covered in thick pink cream paste, the right buttock had bright red drainage, and the right upper thigh had a large bright reddened area. The CNA stated she often applied Desitin to the buttocks but did not put anything on the right thigh because it was new and seemed to be getting bigger. The TAR showed Bacitracin applications documented by the Wing 3 UM and RN A on some shifts, but there were missing signatures for several ordered applications. The assigned LPN could not find the Bacitracin in the treatment cart or stockroom and said she had not yet provided the treatment. The Wing 3 UM stated the resident was not on the wound list and did not have any wounds, said she had not observed the resident’s skin during the week because there were no issues, and later acknowledged she had signed the TAR without providing treatment. The DON acknowledged the sacral and right thigh skin impairments after they were brought to her attention and stated she had not been aware of them previously.
Failure to Monitor Supplemental Oxygen Therapy
Penalty
Summary
The facility failed to monitor supplemental oxygen therapy for a resident with respiratory failure, pneumonia, COPD, sepsis, atrial fibrillation, type 2 diabetes mellitus, and moderate cognitive impairment. The resident was admitted to the facility, then re-admitted from an acute care hospital, and the most recent MDS noted oxygen therapy was administered during the look-back period. On 3/03/26, the resident was observed in bed with a nasal cannula delivering oxygen at 2 LPM, and a joint observation with an RN confirmed continuous supplemental oxygen at 2 LPM. The resident’s active MAR included nebulized respiratory medications, but there were no physician’s orders for supplemental oxygen and no directions to monitor blood oxygen saturations. The care plan addressed oxygen therapy and listed continuous oxygen at 3 LPM, along with nurse monitoring and physician reporting of breathing changes, but the record review found no current oxygen order or monitoring documentation. The RN stated he did not recall checking the resident’s oxygen status during the shift and explained that oxygen saturation should be monitored when supplemental oxygen is being used. Review of the prior 90 days showed oxygen saturations had not been checked for more than six weeks, with the last recorded measurement on 1/27/26. The DON stated nurses were expected to enter orders on re-admission and that the oxygen orders appeared to have been missed.
Incomplete wound documentation and missing outpatient dermatology records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident with non-pressure related skin conditions. The resident was a female with diagnoses including type 2 diabetes mellitus, adult failure to thrive, malnutrition, heart disease, muscle wasting and atrophy of multiple sites, and left lateral forehead squamous cell carcinoma. She had been admitted to the facility and later re-admitted from an acute care hospital. During observation, she was found lying in bed eating breakfast with one small and one large undated bordered gauze dressing with peeling edges on her forehead and scalp, and she stated that skin cancer lesions had been removed at her Dermatologist's office about one week earlier and that facility nurses had not looked at the dressings since then. The resident's active physician orders, MARs/TARs, and care plan did not include monitoring of the head wounds, and the electronic and paper medical records did not contain physician notes or wound care instructions from the outpatient dermatology procedure. A nurse progress note documented that the resident had a head wound dressing after an outpatient appointment, but the record still lacked the most recent dermatology progress notes. The Regional Nurse Consultant stated she could not locate those notes in the medical record, and the DON stated she expected outpatient physician records and related orders to be updated and accessible in the chart, but was unsure what happened to the records.
Failure to Maintain Homelike Environment Due to Unaddressed Maintenance Issues
Penalty
Summary
Surveyors observed multiple maintenance deficiencies on two of three units within the facility, including bubbled and chipped wall paint, broken sheetrock, missing baseboards, holes in walls, unpainted repairs, missing ceramic tiles, and bubbled surfaces on sink bases. These issues were noted in various locations such as the entrance to the 100-unit, outside and inside several resident rooms, and around fixtures like sinks, toilets, and windows. The physical environment in these areas did not meet standards for a safe, clean, comfortable, and homelike setting as required for residents. During interviews, the Maintenance Director stated that daily room rounds were conducted to identify maintenance issues and that staff could report problems verbally or through an electronic system. However, some of the identified deficiencies were already on the project list, but the Maintenance Director could not confirm how long they had been awaiting repair. The Administrator acknowledged the need for repairs to maintain a homelike environment. The facility's policy required timely repair or replacement of damaged structural surfaces, but the observed conditions indicated this was not consistently achieved.
Failure to Monitor Blood Pressure and Timely Collect Urine Specimen
Penalty
Summary
The facility failed to provide appropriate care and treatment according to physician orders and professional standards for two residents. For one male resident with a history of Alzheimer's Disease, stroke, and hypertension, the facility did not consistently monitor and document blood pressure readings as required. Despite being prescribed multiple antihypertensive medications, including one to be administered as needed for elevated systolic blood pressure, nursing staff did not check or record blood pressure at least once daily on 25 occasions over a two-month period. The resident's care plan did not include a cardiovascular/hypertension focus until the day the survey began, and the as-needed medication was never administered, with no documentation to support whether it was needed or not. Interviews with nursing staff, including LPNs, RNs, the Unit Manager, and the DON, revealed a consistent expectation that blood pressure should be checked and documented prior to administering antihypertensive medications. However, the medical record review showed this was not done, and the DON acknowledged the missing entries and the delayed addition of the care plan. Facility guidelines required nurses to obtain and record vital signs prior to medication administration, but this standard was not met for the resident in question. For another resident with diagnoses including muscle wasting, pneumonia, diabetes, and kidney failure, the facility failed to implement a physician's order for a urinalysis with culture and sensitivity in a timely manner. The resident and her son reported symptoms of a urinary tract infection and communicated these to staff, but the urine sample was not collected for over 24 hours after the order was placed. There was no documentation in the medical record explaining the delay, and communication among staff was inconsistent, with some CNAs unaware of the need for specimen collection. The DON confirmed there was no facility policy specifying a 48-hour window for specimen collection and stated that standard practice was to collect samples as soon as possible.
Failure to Accurately Document Medication Administration per Physician Orders
Penalty
Summary
The facility failed to maintain accurate documentation for medication administration for one resident with multiple diagnoses, including quadriplegia and neuromuscular dysfunction of the bladder. The resident had a physician's order for Midodrine 10 mg to be administered three times daily, with instructions to hold the medication if the systolic blood pressure exceeded 120. Review of the Medication Administration Record (MAR) showed that the medication was documented as given on multiple occasions when the resident's systolic blood pressure was above the ordered threshold. Specifically, in November, the medication was recorded as administered 14 times outside the parameters, and in October, 28 times, with several nurses involved in the documentation. Interviews with the assigned RN and the Director of Nursing (DON) confirmed that the MAR contained documentation errors, with the RN acknowledging that she may have checked off the medication as given in error and did not use the appropriate codes for held or not given medications. The DON was unable to provide a reason for the failure to follow the physician's order and acknowledged the expectation for accurate documentation. The facility's policy required corrections to be made in the electronic record, but the errors persisted over multiple months and involved several staff members.
Delay in CPR Due to Code Status Confusion
Penalty
Summary
The facility failed to follow its policy and procedure related to a resident's Full Code status, resulting in a delay in initiating Cardiopulmonary Resuscitation (CPR). The resident, a male with a history of anemia, type II diabetes, and occlusion and stenosis of the carotid artery, was admitted to hospice services with a diagnosis of moderate protein-calorie malnutrition. Despite having a physician's order for full resuscitation, there was confusion regarding the resident's code status, with contradictory orders for Full Resuscitation and Do Not Resuscitate (DNR) entered by an LPN. On the day of the incident, the resident was found unresponsive by a CNA, who reported this to the LPN. The LPN checked the hospice chart, which indicated a DNR order, and called hospice services, which initially confirmed the DNR status. However, hospice later called back to confirm the resident was a Full Code. This confusion led to a delay in initiating CPR, as the LPN waited for confirmation of the resident's code status before starting resuscitation efforts. The facility's documentation and investigation revealed discrepancies in the timeline of events, with conflicting reports from staff, EMS, and hospital records. The Code Blue Worksheet and staff statements indicated different times for when the resident was found unresponsive and when CPR was initiated. The facility's failure to promptly verify and act on the resident's Full Code status placed all residents at risk and resulted in Immediate Jeopardy.
Removal Plan
- CPR was initiated for resident #100 and resident was transferred from the facility with a rhythm via EMS and passed away at the hospital.
- Assistant DON initiated staff education on Code Status Orders and Response Policy and Procedure to include procedure for initiating CPR and documentation of the event. 31 out of 31 licensed nurses were educated. Re-education was initiated for licensed nursing clinical staff to be completed.
- Facility audit of 100 out of 100 residents advance directives was completed, to confirm accuracy of code status present in the front of the medical records and that it matched the physician's orders in the EMR.
- Additional audit of 21 out of 21 residents receiving hospice services conducted to confirm code status of record with hospice matches the facility's record. The hospice chart stored at the facility was combined with the facility's hard chart, removing individual hospice binders.
- The Regional President provided education to the Administrator and Interim DON on their essential core functions and the code of conduct.
- The Risk Management Consultant provided education to the Administrator and DON on the Abuse Prevention Program and conducting thorough investigations.
- A total of 9 Code Blue Drills has been completed covering all shifts in order to ensure staff are knowledgeable and prepared to accurately verify resident code status in an emergency and ensure staff provide CPR in a timely manner.
- Ad Hoc Quality Assurance and Compliance committee reviewed removal plan.
Failure to Timely Report and Investigate Delay in CPR
Penalty
Summary
The facility failed to report potential abuse and/or neglect violations concerning a delay in cardio-pulmonary resuscitation (CPR) for a resident who was a Full Code. The resident, who was on hospice care with a terminal diagnosis, was found unresponsive by a CNA during the night shift. The CNA informed an LPN, who then checked the resident's code status and initially believed the resident was a Do Not Resuscitate (DNR) based on incorrect information from the hospice. This led to a delay in initiating CPR. The LPN called the hospice to verify the resident's code status and was initially told the resident was a DNR. However, the hospice later confirmed that the resident was a Full Code. During this time, the LPN also contacted the physician and the facility's Director of Nursing before starting CPR and calling 911. The EMS report indicated a delay in CPR initiation due to confusion over the resident's code status, with CPR eventually being performed and the resident transported to a hospital. The facility's investigation into the incident was incomplete and inaccurate, as it failed to obtain timely statements from all involved staff and did not submit the required Immediate or 5-Day Report to the State Survey Agency. The Risk Manager acknowledged the discrepancies in the investigation and the need for further information to determine the exact timeline of events. The facility reopened the investigation during the survey due to these inconsistencies and planned to file an immediate report as new information emerged.
Lack of Privacy in Resident Council Meetings Leads to Fear of Retaliation
Penalty
Summary
The facility failed to promote an environment where residents could voice grievances about care and treatment without fear of discrimination or reprisal. During an interview with the Resident Council President, it was revealed that Resident Council meetings were held in a non-private area, specifically the atrium on the back of the 200 hall, which was not conducive to private discussions due to staff presence. The Activity Director confirmed the lack of a private area for these meetings. During a Resident Council Group Meeting held in this open area, 20 residents expressed fear of retaliation if they complained about their care, indicating a significant issue with the facility's handling of resident grievances. A review of Resident Council minutes from March to June 2024 showed few voiced concerns, suggesting a possible underreporting of issues due to fear of retaliation.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to properly and promptly respond to Resident Council concerns and grievances, as evidenced by the Resident Council minutes from June 2023 to June 2024. The minutes revealed that the Council felt their concerns were not addressed or resolved on multiple occasions, including June 2023, August 2023, December 2023, April 2024, May 2024, and June 2024. A new Administrator was introduced in April 2024 and assured the Council that concerns were being addressed, but the Council continued to feel their issues were unresolved in subsequent months. The Activity Director, who worked alone in the department, confirmed that concerns from the April 2024 meeting were not addressed or resolved. The Director explained that Resident Council concerns were communicated to the relevant department, with a two-week follow-up, but resolutions were only received verbally and communicated at the next meeting. The Activity Director was unaware of any unresolved issues, despite the Council's ongoing dissatisfaction. Additionally, the absence of volunteers and the Director's hospitalization led to a lack of activities during that period, further contributing to the Council's grievances.
Failure to Inform Residents of Their Rights
Penalty
Summary
The facility staff failed to review and inform residents of their rights, as evidenced by findings from a Resident Group meeting and review of Resident Council minutes. During a meeting held in an open area near the nurse's station, seven residents and family representatives reported they were unaware of their rights, had not received a copy of their rights upon admission or during their stay, and that these rights were not reviewed during Resident Council meetings. The Resident Council President confirmed that resident rights had not been reviewed in these meetings. A review of the Resident Council minutes from June 2023 to June 2024 showed that while the agenda indicated resident rights were reviewed monthly, there was no documentation or pamphlet provided to confirm this. The Activity Director, responsible for facilitating these meetings since February 2024, could not confirm or provide documentation that resident rights had been reviewed or distributed during the meetings.
Deficiency in Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the interests and well-being of its residents, as evidenced by the lack of engagement for three sampled residents. Resident #10 was observed spending all his time in bed without participation in any group or individual activities. The Activity Director acknowledged that Resident #10 was often left alone, with minimal interaction, and there was no documentation of any activities provided to him. Similarly, Resident #39, who had severe cognitive impairment, was not engaged in any suitable activities. The Activity Director interacted with Resident #39's roommate but not with him, and there was no record of activities provided to Resident #39. Resident #80 expressed dissatisfaction with the lack of activities, noting that there was nothing to do except watch TV. The Activity Director confirmed that during his leave, no activities were conducted, and he struggled to manage the workload alone. He admitted to not having a list of residents requiring one-to-one visits or documentation of such visits. The facility lacked volunteers, and the Activity Director was the sole staff member responsible for activities, which included attending meetings and writing progress notes. The Activity Director was unable to provide Resident Assessment forms or documentation of group participation and one-to-one visits for Residents #10 and #39.
Insufficient Nursing Staff Leads to Delayed Medication Administration
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet the needs of residents, particularly in administering medications on time. Observations and interviews revealed that scheduled 9 AM medications were significantly delayed, with some being administered as late as 11:46 AM and 11:54 AM. This delay was attributed to the insufficient number of nurses available, as one nurse was often assigned to cover multiple wings, leading to a split assignment. The shared use of medication carts further exacerbated the delay, as nurses had to wait for their turn to access the cart. Nurses reported being overwhelmed by the number of residents they were responsible for, with some having up to 47 residents on their assignment. The staffing coordinator and Director of Nursing (DON) acknowledged the staffing issues, noting that the facility was staffed based on census and adjusted for acuity. However, the current staffing levels were insufficient to meet the residents' needs, particularly with the opening of a new wing, which increased the workload without a corresponding increase in staff. The report highlighted that the facility's staffing challenges led to delays in medication administration, with 31 residents receiving their medications outside the prescribed time parameters. Despite concerns being raised by the nursing staff about the unmanageable workload and its impact on resident care, there was no indication of feedback or action from management to address these issues. The DON acknowledged the need for more nurses to provide individualized attention and enhance care, but the current staffing model did not support this need.
Medication Administration Delays Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that scheduled medications were administered within the prescribed time parameters for 31 residents on the 100 Wing during the 7 AM to 3 PM shift. This deficiency was observed through a combination of interviews, observations, and record reviews. Registered Nurse (RN) K and Licensed Practical Nurse (LPN) H were noted to be administering 9 AM medications well past the scheduled time, with some medications being given as late as 1:52 PM. The delay in medication administration was attributed to staffing issues, where nurses were assigned to split assignments between different wings, leading to shared medication carts and further delays. Several residents were directly affected by these delays. For instance, a resident received their 9 AM medications at 11:52 AM, which included medications for high blood pressure, pain, and congestive heart failure. Another resident's medications for anxiety, depression, and high blood pressure were administered at 12:11 PM. The report highlights that the facility's policy required medications to be administered within one hour before or after the scheduled time, a guideline that was not adhered to in these instances. The Director of Nursing (DON) acknowledged the issue, explaining that the split assignment of nurses was due to the facility's census. The DON also noted that there was no documentation indicating that residents, their physicians, or responsible parties were notified of the late medication administration. The Medical Director emphasized the importance of administering medications at specific times and discouraged the practice of splitting nurse assignments between wings.
Repeat Deficiency in Reporting Due to Insufficient Oversight
Penalty
Summary
The facility failed to ensure that its Quality Assessment & Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) committee conducted effective performance improvement activities to sustain prior improvement measures. The facility's QAPI Plan outlined that each Performance Improvement Project (PIP) subcommittee should identify areas for improvement, collect and analyze data, and provide the QAA Committee with a summary report, analysis, and recommendations. However, the facility was cited for a deficiency at F 609 for failing to report during a previous recertification survey and was found to be in noncompliance again for the same issue during the current survey. This repeat deficiency was attributed to insufficient auditing and oversight, as the QAA Committee's action plans/PIPs were typically set for three months and considered complete if the issue was resolved, without ensuring continued audits for previous citations. The Administrator, who had been at the facility for about a month, was unable to confirm whether audits were still being conducted for past citations and acknowledged the system's failure, leading to the repeat violation.
Failure to Update PASARR for Residents with New Mental Disorders
Penalty
Summary
The facility failed to update and refer residents with newly diagnosed mental disorders for Level II Preadmission Screening and Resident Review (PASARR) evaluations. Resident #1, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease and cognitive communication deficit, was later diagnosed with schizophrenia, anxiety, and depressive disorders. Despite these new diagnoses, the facility did not update the resident's Level I PASARR or refer for a Level II PASARR evaluation, as confirmed by the Director of Nursing (DON). Similarly, Resident #72, admitted with bipolar disorder and other conditions, received a new diagnosis of major depressive disorder. However, the facility did not perform a new Level I PASARR or request a Level II evaluation. The Interim DON acknowledged the oversight and confirmed that the resident's PASARR was not updated to reflect the new diagnosis, contrary to the facility's policy requiring PASARR updates following significant changes in a resident's mental condition.
Inaccurate PASARR Evaluation for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure the accuracy of a Level 1 Preadmission Screening and Resident Review (PASARR) evaluation for a resident admitted with a diagnosis of schizophrenia. The resident was admitted from the hospital with this diagnosis, but the Level 1 PASARR completed by the hospital social worker did not include schizophrenia. The interim Administrator indicated that Social Services was responsible for completing PASARRs, while the Social Service Director stated that the Director of Nursing (DON) was responsible for reviewing and ensuring their accuracy. The Interim DON expressed surprise that the resident was admitted with schizophrenia, which necessitated a Level 1 PASARR, and confirmed that it was her responsibility to ensure the accuracy of these evaluations. She acknowledged that the omission of the schizophrenia diagnosis was significant and that another Level 1 PASARR should have been conducted to determine if a Level II PASARR was necessary.
Lack of Documentation for Vaccinations
Penalty
Summary
The facility failed to provide necessary documentation for influenza and pneumococcal vaccinations for four residents out of a sample of five reviewed for immunizations. Specifically, there was no documentation of education, consent, refusal, or medical contraindication for these vaccines. Resident #5, who was admitted with chronic obstructive pulmonary disease, obstructive sleep apnea, dementia, type II diabetes, and heart failure, lacked documentation for the pneumococcal vaccine. Resident #10, with diagnoses including metabolic encephalopathy and dementia, received the influenza vaccine but without documented education or consent. Resident #44, admitted with muscle wasting, metabolic encephalopathy, type II diabetes, and pneumonia, had no documentation for either vaccine. Similarly, Resident #55, with hypertensive emergency and stage 4 chronic kidney disease, received the influenza vaccine without the necessary documentation. The Director of Nursing confirmed the absence of records for education, consent, refusal, or contraindication for the vaccines in question. The facility's policy mandates that all residents be offered the pneumococcal vaccine unless there is documented evidence of prior administration, medical contraindication, refusal, or no order. The influenza vaccine should be offered during the optimal immunization period, typically from October to March. The policy also requires staff to screen new admissions for previous pneumococcal vaccine administration, obtain consent or declination for immunizations, secure a physician's order, review vaccine information with the resident or their representative, and document these actions in the medical record. However, these procedures were not followed for the residents mentioned, leading to the deficiency noted in the report.
Deficiencies in Documentation and Medication Administration
Penalty
Summary
The facility failed to ensure complete and accurate medical records for a resident who experienced a change in condition. A male resident, admitted with diagnoses including anemia, diabetes, and malnutrition, was under hospice care. On a specific date, a Licensed Practical Nurse (LPN) documented that the resident had expired, but there was no prior documentation in the resident's clinical records indicating when the change in condition was identified. Interviews with staff revealed that the resident was found unresponsive earlier than documented, and actions taken were recorded on a CPR log rather than in the clinical record. The Director of Nursing (DON) and other staff acknowledged the lack of documentation in the resident's records. Another deficiency was identified in the administration of medication for a resident with glaucoma. The resident was supposed to receive eye drops twice a day, but on one occasion, the resident and her daughter reported that the medication was not administered as scheduled. The Medication Administration Record (MAR) inaccurately showed that the eye drops were given. An LPN admitted to documenting the administration of the medication before actually administering it, which was against the facility's policy. The DON confirmed that this practice was incorrect and could lead to inaccuracies in medication administration records. These deficiencies highlight issues with documentation and medication administration within the facility. The lack of proper documentation for the resident who expired and the premature recording of medication administration for another resident indicate a failure to adhere to professional standards and facility policies. These actions and inactions contributed to the deficiencies identified during the survey.
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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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