Villages Healthcare And Rehabilitation Center, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Lady Lake, Florida.
- Location
- 900 Highway 466, Lady Lake, Florida 32159
- CMS Provider Number
- 106099
- Inspections on file
- 27
- Latest survey
- December 12, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Villages Healthcare And Rehabilitation Center, The during CMS and state inspections, most recent first.
A resident with a nephrostomy catheter was observed with an old dressing showing bloody drainage that had not been changed since return from a hospital stay, despite existing physician orders and facility policies for catheter and wound care. The resident reported no dressing change since hospital discharge. An APRN and the DON stated that protocols and expectations required nurses to follow nephrostomy care orders, including daily or ordered catheter care. Two LPNs acknowledged they did not perform the documented dressing changes and may have inadvertently checked off the tasks, resulting in the nephrostomy dressing not being changed as ordered and without a recorded reason for not following the physician’s orders.
A cognitively intact resident with an indwelling catheter and nephrostomy had physician orders for daily cleansing with normal saline, drying, and bandage application to the nephrostomy site on the night shift and as needed, but the MAR/TAR showed no nephrostomy dressing changes for an extended period, despite these active orders. Later, an order was written to send the resident to the ED for evaluation and treatment of hematuria, after which daily nephrostomy dressing changes began to be documented. The physician reported that nurses were responsible for performing skin and wound care per orders and documenting treatments, and that they did not fulfill these responsibilities in this case.
A resident with a right nephrostomy was observed with an old dressing showing bloody drainage that had not been changed since return from the hospital, despite physician orders for daily site care. Admission documentation failed to record the nephrostomy, even though other records identified it, and there were no nephrostomy site care orders or documented dressing changes for an extended period after admission. Later, when orders for daily cleansing and bandage application were in place, LPNs acknowledged they had not actually performed some documented dressing changes. These actions and omissions were inconsistent with facility policies on indwelling catheter and wound care, which required appropriate assessment, orders, performance, and documentation of treatments.
A resident with a Foley catheter was observed wearing a hospital gown instead of personal clothing, despite expressing a preference to wear his own clothes. Staff did not offer or assist the resident with dressing in his personal attire, contrary to facility policy and the resident's care plan, resulting in a failure to maintain the resident's dignity.
A resident with a recent hip fracture and severe malnutrition did not receive post-operative wound care as ordered by the physician, including timely cleaning, dressing changes, and staple removal. Review of the treatment record showed missing documentation for these required interventions, and the DON confirmed that physician orders were not followed as expected.
A resident with impaired mobility and a history of pressure ulcers was not turned or repositioned as required, despite a care plan and facility policy mandating frequent repositioning and use of pressure-reducing devices. The resident remained in the same position for an extended period, leading to the recurrence of a pressure ulcer on the sacrum.
The facility failed to consistently monitor and document weights and supplement intake for three residents with protein-calorie malnutrition, resulting in missed weight records and lack of documentation on supplement consumption, despite care plans and physician orders requiring these interventions. Staff interviews revealed inconsistent practices and communication breakdowns regarding weight monitoring and nutritional assessments.
A resident with an indwelling urinary catheter was observed with the catheter collection bag lying on the floor, contrary to the care plan and facility policy, which require the bag to be properly positioned to promote infection control. The DON confirmed the bag should not be on the floor.
A resident was transferred to the hospital after the spouse called 911, but the physician was not notified of the transfer or the resident's return. The nurse on duty, who was new, did not follow the facility's policy to inform the provider, and there was no documentation of physician notification. Staff interviews confirmed that the expected procedure was not followed, and the physician stated they were not informed as required.
Staff failed to perform hand hygiene before and after administering medications to two residents, including handling a dropped pill with bare hands and returning it to the medication cup. LPNs involved acknowledged not following infection control protocols, and facility leadership confirmed these actions did not meet established policy.
A resident with acute kidney injury, dehydration, and poor oral intake did not consistently receive prescribed IV fluids as ordered. Staff interviews and observations revealed missed or improperly timed IV administration, despite the resident's ongoing risk for dehydration and reliance on supplements and IV therapy. Facility policies required adherence to physician orders for hydration, but these were not followed, resulting in a deficiency.
A resident with multiple medical conditions requiring enteral nutrition did not receive tube feedings and water flushes at the physician-ordered rates. Observations showed the feeding pump was set below the prescribed rates for both nutrition and hydration, and staff failed to verify or clarify the correct settings, resulting in the resident not receiving care as ordered.
Two residents receiving oxygen therapy were observed with undated oxygen tubing, despite facility policy and physician orders requiring weekly changes and proper labeling. The DON confirmed that staff are expected to change and date tubing every seven days, but observations showed this was not done, resulting in non-compliance with professional standards for respiratory care.
Surveyors found unsanitary conditions in three nourishment rooms, including splattered and sticky substances on freezers, refrigerators, and microwaves. The Assistant Dietary Manager confirmed that daily cleaning had not yet been checked as required by facility policy.
The facility did not ensure accurate documentation and administration of medications for two residents. One resident's MAR lacked required blood pressure and heart rate documentation before administration of metoprolol, and staff admitted to using placeholders instead of actual vital signs. Another resident's MAR showed IV fluids were given as ordered, but observation and staff interviews confirmed the IV was not administered. These actions did not comply with facility policy or physician orders.
Staff failed to consistently follow infection control protocols, including not wearing required PPE during high-contact care for residents with wounds or G-tubes, neglecting hand hygiene during medication administration and wound care, and improperly handling tube feeding products by leaving them open, undated, and unrefrigerated in resident rooms. These deficiencies were observed across multiple staff roles and confirmed through interviews and record reviews.
Failure to Follow Physician Orders for Nephrostomy Dressing Care
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for nephrostomy care for one resident. On observation, the resident was seen in bed with a gauze pad and transparent occlusive dressing over a nephrostomy catheter insertion site on the right lower back. The dressing showed a half-dollar sized area of bloody drainage and was dated several days prior to the observation. The resident reported that she had previously been hospitalized due to blood in her nephrostomy drainage bag and dislodgement of the tube, which was reinserted at the hospital, and that the dressing had not been changed since her return. Her admission record showed an admission date in April 2026 with diagnoses including a fracture of the neck of the left femur. Record review and staff interviews showed that there were physician orders and facility policies in place for catheter and wound care, including daily catheter care or as ordered, and treatment of skin impairments. The APRN stated that protocols for catheter care existed and that nurses were expected to follow nephrostomy care orders. The DON stated that the admitting nurse was expected to obtain nephrostomy care orders and that nurses were expected to follow them. However, two LPNs each confirmed they had not performed the nephrostomy dressing changes on the dates documented and suggested they may have inadvertently checked off the task in error. This resulted in the nephrostomy dressing not being changed as ordered, without a documented reason in the medical record for not following the physician’s orders.
Failure to Provide and Document Ordered Nephrostomy Site Care
Penalty
Summary
Nursing staff failed to provide and document ordered nephrostomy site care for a cognitively intact resident with an indwelling catheter and nephrostomy. The resident’s Admission/5-day Medicare MDS dated 4/20/2026 showed a BIMS score of 15/15 and documented the presence of an indwelling catheter and nephrostomy. Physician orders dated 4/27/2026 and 4/28/2026 directed staff to cleanse the nephrostomy site with normal saline, pat the area dry, and apply a bandage daily on the night shift and as needed. Despite these orders, the MAR/TAR from 4/14/2026 through 4/27/2026 contained no documentation of nephrostomy dressing changes. Subsequently, a physician order dated 4/30/2026 instructed that the resident be sent to the ED for evaluation and treatment for hematuria. The MAR/TAR from 5/01/2026 through 5/05/2026 then showed documentation of daily nephrostomy dressing changes. During an interview on 5/06/2026, the physician stated that nurses were expected to perform skin and wound care, follow physician orders, and contact the physician as needed, and that in this case the nurses did not do their due diligence. Facility wound care expectations included that wound care procedures and treatments be performed according to physician orders, maintain proper technique, and be documented in the clinical record when performed.
Failure to Provide Ordered Nephrostomy Care and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate and appropriate health care related to nephrostomy care for one resident with an indwelling nephrostomy catheter. On observation, the resident was noted sitting up in bed with a gauze pad and transparent occlusive dressing over the right lower back nephrostomy insertion site that had a half-dollar sized area of bloody drainage and was dated several days earlier. The resident stated that she had previously gone to the hospital because there was blood in her nephrostomy drainage bag and the tube had been pulled out, and that the dressing had not been changed since her return from the hospital. The resident’s records showed an admission date of 4/14/2026 with diagnoses including a left femur neck fracture, other artificial openings of urinary tract status, and local skin and subcutaneous tissue infection. Her most recent MDS documented that she was cognitively intact (BIMS 15/15) and had both an indwelling catheter and an ostomy (right nephrostomy). The Medical Certification for Medicaid LTC Services also documented a right nephrostomy. However, the Nursing Admission Assessment documented that she did not have a catheter and contained no documentation of the nephrostomy. From 4/14/2026 through 4/27/2026 there were no physician orders for nephrostomy site care and no nephrostomy dressing changes documented on the MAR/TAR during that period. Physician orders later included instructions to empty the nephrostomy bag every shift and, beginning 4/27/2026 and again on 4/28/2026, to cleanse the nephrostomy site with normal saline, pat dry, and apply a bandage daily on night shift and as needed. MAR/TAR review from 5/01/2026 through 5/05/2026 showed documentation of daily nephrostomy dressing changes, but two LPNs interviewed admitted they had not actually performed the dressing changes on specific dates despite having checked them off. The DON stated that the expectation was for the admitting nurse to obtain nephrostomy care orders and for nurses to follow those orders. Facility policies on indwelling catheters and wound care required appropriate documentation, daily care as ordered, admission skin/pressure risk assessment, identification of pre-existing conditions, and performance and documentation of wound care per physician orders, which were not consistently followed in this case.
Failure to Honor Resident's Preference for Personal Clothing
Penalty
Summary
A deficiency was identified when a resident was observed lying in bed on an air mattress, wearing a hospital-style gown with a white blanket over his legs, and his personal clothing placed on the back of his wheelchair. The resident had a Foley catheter in place and stated during an interview that he preferred to wear his own clothes but was not given the option to get dressed that morning. He believed staff did not want to dress him due to the catheter tube. Subsequent observation later in the day confirmed the resident remained in a hospital gown. Review of the resident's care plan indicated that assistance with activities of daily living (ADLs), including dressing, should be provided as needed. The facility's policy also required staff to provide ADL care with dignity, privacy, and respect, unless otherwise indicated by the resident. The Director of Nursing confirmed that it was her expectation for residents to be dressed in their personal clothing unless they preferred otherwise. The failure to offer or assist the resident with dressing in his personal clothing, despite his preference and the facility's policy, resulted in a lack of dignity and respect for the resident.
Failure to Provide Post-Operative Wound Care per Physician Orders
Penalty
Summary
The facility failed to provide post-operative wound care according to physician orders for one resident who was admitted with a displaced intertrochanteric fracture of the right femur and severe protein-calorie malnutrition. Physician orders specified a wound care regimen that included cleaning the right hip with hibiclens on day 5 post-operation, removing the aquacel dressing and cleaning the surgical site with hibiclens and 4 by 4s on day 10 post-operation, and removing staples and applying steri strips for two weeks. Review of the resident's Treatment Administration Record (TAR) for May 2025 showed no documentation that these orders were followed as directed. During an interview, the Director of Nursing confirmed that the expectation is for all physician orders to be followed or for the physician to be notified if orders are not carried out. The Director also acknowledged that the resident's staples should have been removed on the specified date according to the orders. Facility policy requires wound care procedures and treatments to be performed according to physician orders and for the physician to be contacted for order changes or to notify of changes in skin condition or refusals of care.
Failure to Prevent Recurrence of Pressure Ulcer Due to Inadequate Repositioning
Penalty
Summary
A resident with a history of pressure ulcers and multiple risk factors, including impaired mobility, incontinence of bowel and bladder, and a recent femur fracture, was observed lying on his back in bed on an air mattress for an extended period. During two separate observations on the same day, the resident remained in the same position, and he reported that he had not been turned since the previous night and was experiencing pain and developing a sore. Upon further observation by nursing leadership, the resident's lower back was found to be bright red with a small open area on the left side of the sacrum, consistent with a pressure ulcer. The resident's care plan included interventions such as regular turning and repositioning, use of a pressure-reducing mattress, and monitoring for skin breakdown. Despite these documented interventions, staff failed to implement the required turning and repositioning schedule, as confirmed by the resident's statement and direct observation. The facility's policy and wound care consult also emphasized the need for ongoing pressure reduction and repositioning, but these measures were not consistently followed, resulting in the recurrence of a pressure ulcer.
Failure to Monitor and Document Nutritional Status and Supplement Intake
Penalty
Summary
The facility failed to recognize, evaluate, and address the nutritional needs of residents at risk for or experiencing impaired nutrition, as evidenced by the lack of consistent weight monitoring and documentation for three residents with diagnoses including severe protein-calorie malnutrition. For one resident, there was only a single weight recorded after admission, with no subsequent weights documented, despite care plans and facility policy requiring regular weight monitoring. The resident was on enteral feedings due to dysphagia and esophageal cancer, and the Registered Dietitian (RD) acknowledged not bringing the missing admission weight to anyone's attention. Interviews revealed inconsistent practices and a lack of a set frequency for obtaining weights, with staff relying on ad hoc communication rather than systematic monitoring. Another resident experienced a significant weight loss of 15% over three months, with no weights documented for two consecutive months. The resident was at risk for malnutrition, had a therapeutic diet, and was prescribed a house nutritional supplement, but there was no documentation of the percentage of supplement consumed. The RD and nursing staff described a process where weights and supplement intake were to be monitored and communicated, but gaps in documentation and follow-through were evident. The resident reported dissatisfaction with the food and was unaware of the extent of their weight loss. A third resident, also diagnosed with protein-calorie malnutrition, had no documented weights for two months and no records of supplement intake, despite orders and care plans specifying these interventions. Staff interviews confirmed that weights should be obtained upon admission, monthly, and as needed, but acknowledged communication breakdowns and missing documentation. The facility's own policy required weights to be recorded upon admission and monthly, with the RD reviewing all admission weights for possible intervention, but these procedures were not consistently followed for the residents reviewed.
Failure to Maintain Proper Placement of Urinary Catheter Collection Bag
Penalty
Summary
During an observation, a resident with an indwelling urinary catheter was found lying in bed with the catheter collection bag placed on the floor. The resident's care plan specified that the catheter bag should be kept below bladder level, covered for dignity, and that catheter care should be provided as ordered. The facility's policy also required staff to ensure proper placement of catheter tubing and collection bags to promote infection control and prevent contamination. The Director of Nursing confirmed during an interview that the catheter bag should be hanging on the bed frame and not on the floor. These findings indicate that staff failed to follow both the resident's care plan and facility policy regarding the proper placement and handling of the urinary catheter collection bag.
Failure to Notify Physician of Resident Hospital Transfer and Return
Penalty
Summary
The facility failed to notify the physician when a resident was transferred to and returned from the hospital. According to nursing progress notes, the resident's wife requested a hospital transfer and called 911, with facility staff only becoming aware when paramedics arrived. There was no documentation in the medical record indicating that the resident's physician was notified of either the transfer or the return from the hospital. Interviews with staff revealed that the nurse on duty was new and did not know to call the physician, instead contacting the previous Director of Nursing. Other staff confirmed that the expected procedure was to notify the physician and document the notification, but this was not done. The Director of Nursing and other staff stated that the facility's policy requires notification of the physician, family, and documentation of any significant change in condition, including hospital transfers. The physician confirmed that they were not notified and expected to be informed of such events. The facility's written policy also specifies that the primary physician should be updated about changes in condition, and if unavailable, the medical director should be contacted. The failure to notify the physician and document the notification represents a deviation from both facility policy and standard practice.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
Staff failed to perform proper hand hygiene during medication administration for two residents. In one instance, an LPN entered a resident's room, used a blood pressure cuff, and administered oral medications without performing hand hygiene before or after the procedure. The LPN also handled equipment and medication cups without cleaning hands between tasks or after leaving the resident's room. The LPN confirmed during an interview that hand hygiene was not performed as required. In another case, a different LPN prepared oral medications, entered a resident's room without performing hand hygiene, and handed the medication cup to the resident. When the resident dropped a pill on her shirt, the LPN picked up the pill with bare hands and placed it back into the medication cup, rather than using gloves and discarding the pill. The LPN acknowledged not following proper hand hygiene or glove use. Facility policy and interviews with the DON and unit manager confirmed that staff are expected to perform hand hygiene before and after medication administration and to use gloves and discard dropped pills, but these procedures were not followed.
Failure to Ensure Proper Hydration for Resident with AKI and Poor Oral Intake
Penalty
Summary
A deficiency was identified when the facility failed to ensure proper hydration for a resident with a history of acute kidney injury (AKI), dehydration, significant weight loss, variable oral intake, and diuretic use. The resident had a physician's order for intravenous (IV) sodium chloride solution to be administered three times a week to address hydration needs. Observations and interviews revealed that the resident was not receiving IV fluids as ordered, with staff noting that the IV was not started as scheduled and that sometimes night nurses administered fluids earlier than ordered. On one occasion, the resident was not hooked up to IV fluids in the morning, and the unit manager confirmed that the scheduled IV was not administered the previous night. The resident was also observed to have poor oral intake, often refusing meals and not consuming adequate fluids, which was acknowledged by staff as a reason for providing supplements and IV fluids. Despite these interventions, the resident was not observed to be receiving IV fluids during multiple observations, and documentation inconsistencies were noted regarding the administration of the IV fluids. The facility's policies required medications and hydration to be provided as ordered, but these were not consistently followed, resulting in a failure to maintain the resident's hydration status as prescribed.
Failure to Administer Enteral Nutrition and Hydration as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of metabolic encephalopathy, diabetes, obesity, and dysphagia, who was dependent on enteral nutrition, did not receive tube feedings and water flushes as ordered by the physician. Multiple observations over two days showed the resident's feeding pump was consistently set at 45 ml/hr for Glucerna 1.5 and 30 ml/hr for water flush, instead of the physician-ordered 60 ml/hr for Glucerna 1.5 and 55 ml/hr for water. The resident's medical records and dietary notes confirmed the prescribed rates, which were intended to meet the resident's full nutritional and hydration needs due to their NPO status and risk for malnutrition. Staff interviews revealed that nursing staff were unaware of the correct settings and did not verify or clarify the physician's orders when discrepancies were noted. The LPN acknowledged the error after checking the orders, and the Unit Manager was not informed of any changes. Even after the feeding rate was corrected, the water flush remained incorrect. The facility's policy required verification and adherence to physician orders for enteral feedings, which was not followed in this instance.
Failure to Date Oxygen Tubing During Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents who were receiving oxygen therapy. During observations, both residents were found using nasal cannulas for oxygen administration, but the oxygen tubing in use was not dated as required. The electronic medication administration record and physician's orders specified that oxygen tubing and bags should be changed and dated weekly, specifically every Thursday during the midnight shift. However, during multiple observations, the tubing for both residents lacked any date, indicating that staff did not follow the established protocol for labeling and dating oxygen equipment. Interviews with the Director of Nursing confirmed that nurses are expected to change, label, and date the oxygen tubing every seven days, in accordance with facility policy. The facility's written policy on oxygen administration also requires that weekly tubing changes be documented and that the tubing be appropriately dated to demonstrate compliance. The failure to date the oxygen tubing as observed for both residents directly contravened these documented procedures and expectations.
Unsanitary Conditions in Nourishment Rooms
Penalty
Summary
Surveyors observed that the facility failed to maintain kitchen equipment in a clean and sanitary condition in three out of four nourishment rooms. Specifically, there were brown and red splattered substances on the interior base of the freezer and an orange sticky substance on the inside walls of the microwave in one nourishment room. In another nourishment room, a brown splattered substance was found on the back wall of the refrigerator, food buildup was present on the microwave oven plate, and opaque splatters were noted on the exterior front glass of the microwave. In a third nourishment room, brown splattered substances were observed on the lower refrigerator drawers and a brown sticky buildup was found on the interior base of the freezer. The Assistant Dietary Manager confirmed during interview that the nutrition rooms should be cleaned daily and acknowledged that rounds to check cleanliness had not yet been completed that morning. Review of the facility's kitchen sanitation policy indicated that kitchen areas and equipment are required to be kept clean and in good repair.
Failure to Accurately Document and Administer Medications as Ordered
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for two residents in relation to medication administration. For one resident prescribed metoprolol with specific parameters to hold the medication if systolic blood pressure was less than 110 or heart rate below 60 BPM, the Medication Administration Record (MAR) did not include documentation of the resident's heart rate or blood pressure prior to administration on multiple occasions. Nursing staff reported that vital signs were sometimes entered later or marked as 'NA' as a placeholder, contrary to facility expectations and policy, which require documentation of vital signs before administering cardiac medications. For another resident with physician orders for intravenous sodium chloride solution three times a week for acute kidney injury and dehydration, the MAR indicated the IV fluid was administered, but observation and staff interviews revealed the IV was not actually given as ordered. Staff noted that sometimes IV fluids were started earlier than ordered, or not at all, and the Unit Manager confirmed that the IV fluid was not hung as documented. Facility policies require medications and services to be administered and documented as prescribed, but these requirements were not met in these cases.
Failure to Adhere to Infection Control Protocols and Safe Handling of Medical Products
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols in several observed instances. Staff did not follow posted Enhanced Barrier Precautions signage, such as failing to wear gowns and gloves when required for residents with wounds or devices like G-tubes. In one case, a disposable gown was left hanging in a resident's room, and staff were unaware of its purpose or the need for proper use of personal protective equipment (PPE). Multiple staff members, including CNAs and LPNs, entered rooms or provided care without donning appropriate PPE, despite clear signage and physician orders indicating the need for enhanced precautions due to conditions such as recent C. difficile infection, surgical wounds, or G-tube presence. Hand hygiene practices were not consistently followed during medication administration and wound care. An LPN was observed retrieving and administering medication to a resident without performing hand hygiene after touching multiple surfaces, including a medication dispensing machine and secured doors. During wound care, the Assistant Director of Nursing did not change gloves or perform hand hygiene between cleaning the wound and applying ointment and a new dressing, contrary to established infection control procedures. Additionally, the facility did not properly handle or store tube feeding products according to manufacturer recommendations. Observations revealed that tube feeding bottles were left open, undated, and uncovered in resident rooms, and staff did not ensure that these products were refrigerated or used within the recommended timeframe. These lapses were confirmed by staff interviews and were not in accordance with facility policy or manufacturer guidelines.
Latest citations in Florida
Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
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