Vivo Healthcare Lakeland
Inspection history, citations, penalties and survey trends for this long-term care facility in Lakeland, Florida.
- Location
- 1919 Lakeland Hills Blvd, Lakeland, Florida 33805
- CMS Provider Number
- 105354
- Inspections on file
- 26
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Vivo Healthcare Lakeland during CMS and state inspections, most recent first.
A resident with intact cognition and multiple medical conditions reported ongoing dental pain, altered eating habits, and longstanding difficulty obtaining dental care, stating that appointments were delayed, had to be initiated by the resident, and were sometimes cancelled without explanation. Records showed a prior in-house dental visit documenting a mobile root fragment causing discomfort and the resident’s interest in extraction, but there was no evidence of follow-up, no documentation of tooth pain or dental issues in progress notes, and no Social Services documentation of offering or arranging dental services or explaining the lack of access. The SSD confirmed the absence of follow-up despite a later on-site visit by the dental provider and cited the resident’s low income and inability to cover dental liability, while the facility’s policy committed to assisting residents in obtaining routine and emergency dental care for damaged teeth and other urgent oral problems.
A resident with intact cognition and multiple medical conditions reported ongoing dental pain and difficulty eating, stating that dental care access was a persistent problem, with appointments delayed or cancelled without explanation. Facility records showed a prior in-house dental visit documenting a mobile root fragment causing discomfort and the resident’s interest in extraction, but there was no subsequent documentation of pain, broken tooth, or dental follow-up in progress notes or Social Services notes, and the MDS oral/dental section did not reflect the resident’s reported issues. The dental provider later returned on-site, but the resident was not seen, and no rationale was documented for the lack of timely dental services.
Surveyors found deficiencies in infection control, including improper storage and disposal of toileting items in two resident rooms, staff with artificial nails exceeding policy length, and a CNA failing to perform hand hygiene during meal service after coughing and wiping her face before feeding a resident.
Two residents with cognitive and physical impairments were observed with their briefs exposed and visible from the hallway, in violation of facility policy and staff training on resident dignity and privacy.
Surveyors found that several resident rooms had environmental deficiencies, including a picture hanging off the wall, a high-rise toilet seat with dirty tape, and torn drywall behind a bed. Additionally, a shower room was used to store equipment such as a bed, walker, and reclining chairs. Staff interviews revealed that these issues were not reported or addressed as required by facility policy.
A resident with severe cognitive impairment sustained bruising and swelling around the eye after another resident mistakenly entered her bed, resulting in head-to-head contact. Although staff witnessed the incident and documented the injury, the DON and NHA did not report the event to state agencies, citing lack of intent or aggression, despite facility policy requiring such reporting.
Two residents with dementia and additional mental health diagnoses did not have updated PASRR assessments, as required. The Social Services Director, responsible for PASRR screenings, was unfamiliar with regulatory requirements and did not consistently identify when a Level II PASRR was needed, resulting in incomplete assessments.
The facility did not ensure comprehensive, person-centered care plans for three residents with severe cognitive impairment, resulting in repeated falls, unaddressed injuries, and unmanaged behavioral issues. Staff interviews revealed a lack of awareness and understanding of care plan interventions, and care plans were not consistently updated or communicated following significant changes in residents' conditions.
Two residents did not receive necessary assistance with ADLs, including bathing and grooming. One resident, dependent for bathing and needing supervision for oral hygiene, was left with unwanted facial hair, while another, requiring full assistance for bathing, missed multiple showers and was noted to have a foul odor. Staff did not consistently offer or document required care, despite facility policy and resident care plans indicating these needs.
The facility failed to schedule a stat urology consult and follow up on an MRI with sedation for a resident with complex medical needs, and did not administer medications on time for two other residents. Staff interviews revealed a lack of awareness and communication regarding appointment scheduling, and medication passes were routinely late due to staffing and workflow issues, contrary to facility policy.
A resident with multiple psychiatric diagnoses was prescribed several psychotropic and other medications, but side effect monitoring for antipsychotic use was discontinued while the medications continued. The care plan and facility policy required ongoing monitoring and documentation of side effects, but this was not maintained, as confirmed by the DON.
A registered nurse was observed making two medication errors while administering medications to a resident, resulting in a medication error rate of 7.14%. The nurse incorrectly measured and mixed MiraLAX with other medications and dispensed an extra Losartan tablet, actions that did not align with the resident's orders or facility policy.
Surveyors found improper food storage practices and expired food items in kitchen areas, including a non-functioning walk-in freezer containing food, a fridge with spoiled produce and expired pickles, and a trailer freezer with open boxes. The CDM confirmed food was stored incorrectly and that expired items were not discarded, contrary to facility policy.
Two residents with severe cognitive impairment and known elopement risk were able to leave the facility unsupervised due to lapses in staff supervision, unsecured exit areas, and delayed notification of law enforcement. One resident walked a significant distance and was found on a highway, requiring hospitalization for dehydration and acute kidney injury, while another was found outside the building after triggering an exit alarm.
Two residents with severe cognitive impairment and a history of wandering were able to exit the facility unsupervised, with one resident found walking away from the building after triggering a door alarm and another resident leaving through a damaged patio screen and being found on a highway. Staff interviews revealed lapses in supervision, communication, and timely response, and the facility lacked an effective QAPI plan to prevent such elopements.
A facility failed to address flooring hazards in a memory care unit, leading to a resident's injury. The resident, who had difficulty walking, was injured due to an uneven walkway caused by a concrete patch left by plumbers. The DOM delayed repairs, opting for temporary fixes that were inadequate, resulting in the resident requiring surgical intervention and experiencing a decline in mobility and daily living activities.
A resident in a memory care unit suffered a significant injury after tripping over an unrepaired clean-out drain in a high-traffic area. The facility failed to promptly address the flooring hazard, relying on inadequate temporary measures. This oversight resulted in the resident's decreased ability to walk independently and perform daily activities, requiring surgical intervention.
A flooring hazard in the memory care unit of a facility led to a resident tripping and sustaining a serious injury. The issue involved a missing clean-out cover that was inadequately repaired with a metal sheet and tape, causing the resident to fall. The resident, who had difficulty walking, required hospitalization and surgery. The facility's maintenance records indicated a delay in addressing the hazard, which was in a high-traffic area, placing others at risk.
A facility failed to protect resident privacy when a staff member posted unauthorized videos of residents on social media. The videos, featuring residents from the secure memory care unit, were shared without consent, violating their dignity and privacy. Many residents were unable to provide informed consent due to cognitive impairments, and the facility's social media policy was not followed.
A facility failed to protect resident privacy and confidentiality when videos of residents, many with severe cognitive impairments, were posted on social media without consent. The videos, initially shared by an Admissions Coordinator, were widely disseminated, and family members were not informed or asked for consent. The facility's policy prohibits such actions, yet the breach went unnoticed by administration until it was reported.
The facility failed to maintain admission paperwork, including agreements and consents, for four residents. The Administrator confirmed the absence of these documents and was unsure of their whereabouts, prompting the facility to begin obtaining new paperwork.
A facility failed to maintain accurate and complete medical records for a resident who experienced a change in condition. Despite the initiation of emergency procedures and notification of EMT, the clinical record did not reflect these actions. The Director of Nursing confirmed the documentation was incomplete, violating the facility's policy on timely and accurate record-keeping.
A resident in the memory care unit suffered a major injury due to a fall caused by an unsafe environment with uneven flooring. The facility failed to report the incident as required by policy, and the Director of Nursing did not consider it adverse since the plan of care was followed. The Director of Maintenance addressed the flooring issue only after the incident, highlighting a lack of prompt action to ensure resident safety.
A resident in a memory care unit suffered a major injury due to a fall in a high-traffic area with uneven flooring. The facility failed to report the incident as required, despite the resident's care plan indicating a risk for falls. Temporary fixes to the flooring hazard were inadequate, and staff did not adhere to reporting policies.
A resident with acute failure and supplemental support dependence was found unresponsive after a room transfer. Despite emergency measures being initiated, the facility failed to document these actions in the clinical record, as confirmed by the DON. This omission violated the facility's policy requiring accurate and timely documentation of resident care.
A facility failed to provide timely access to medical records for a resident with Alzheimer's and other conditions, despite a request from the family made nearly 11 months prior. The Medical Records Director delayed the release due to instructions from the new company ownership and lack of contact with company attorneys. The facility's policy requires timely access to records, which was not adhered to in this case.
A resident who had undergone a renal transplant did not receive physician-ordered laboratory tests, including weekly Creatinine levels and Vitamin B12/Folate levels. The facility's staff failed to ensure these tests were completed due to a lack of awareness and understanding of the process for confirming and entering laboratory orders. The facility's policy emphasized the need for timely laboratory services, but the deficiency was evident as the orders were not properly entered or confirmed, leading to missed tests.
Failure to Provide Timely Dental Services for Resident with Documented Tooth Fragment
Penalty
Summary
Failure to ensure dental services were provided occurred when a resident with intact cognition and documented dental needs did not receive timely follow-up care. The resident, admitted with diagnoses including muscle wasting, legal blindness, and anemia, reported that obtaining dental care at the facility had always been a problem. He stated his mouth felt "weird," he had ongoing dental pain when eating, and he therefore mainly ate soft foods. He reported seeing the dentist only once and not thereafter, and described repeated issues with scheduling, including the facility attributing delays to insurance or paperwork, the resident having to initiate appointments himself, and last-minute cancellations without explanation. Despite these complaints, the resident’s MDS oral/dental section showed no responses indicating mouth or facial pain, chewing difficulty, or problems with teeth or dentures. Record review showed a dental order from an outside dental service documenting that the resident had a mobile root fragment on tooth #8 causing slight discomfort and that the resident was interested in extraction. However, there was no evidence in the progress notes of documentation of tooth pain, a broken tooth, or any follow-up dental services. Social Services notes contained no documentation of offering dental services or any rationale for the lack of access to dental care. The Social Services Director confirmed that the resident had been seen by an in-house dentist for the root fragment and expressed interest in extraction, but could not explain why no follow-up occurred and acknowledged that the resident had not been seen when the dental company was later on-site. The SSD also stated the resident’s income was very low and that he did not have enough to cover patient liability for dental services, and that attempts were being made to contact family about payment responsibility. The facility’s dental policy stated it would assist residents in obtaining routine and emergency dental care, including treatment of broken or damaged teeth or other oral problems requiring immediate attention.
Plan Of Correction
The statements made in this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations, the Center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the Center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 was immediately assessed for further dental needs or concerns on 3/27/2026 by LPN Unit Manager. Pain assessment completed for resident # 1 with no complaints of dental pain at the time assessment was completed on 3/27/26 by LPN Unit Manager. On 3/26/26 a dental appointment was immediately scheduled by Social Service Director for 4/10/2026 with Facility dental provider. 2. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken. A facility wide quality review audit was initiated on 3/27/2026 by social services for long term care residents residing in the facility to identify those with dental needs or concerns. Any identified residents with dental needs or concerns will be referred to dental services and scheduled for evaluation and treatment as indicated, as appropriate. . What measures will be put into place or what systematic changes you will make to ensure that the deficient practiceOn 3/27/2026 The Social Service Director and Social Services Assistant was educated by NH/designee on the components of this regulation with emphasis on ensuring that residents with dental issues or concerns receive dental referrals and evaluation and treatment as indicated.New residents upon admission will be assessed for dental services and residents residing in the facility with identified dental issues/ concerns will be seen by dental services and any follow-up needed will be addressed. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place The NH/AV Designee will audit 10 residents weekly x 4 weeks, twice monthly x1 month; then monthly and as indicated until substantial compliance is met on the following: Ensuring that any identified resident with dental issues or concerns will be seen by the dental services and any follow up needed will be addressed. Information will be brought to QAPI monthly and monitored until substantial compliance is met.
Failure to Ensure Timely Access to Needed Dental Services
Penalty
Summary
The facility failed to ensure access to needed dental services for one resident, resulting in a deficiency under the requirement to provide access to dental and other health-related services. The facility’s undated Dental Policy stated it would assist residents in obtaining routine and emergency dental care, including treatment for broken or otherwise damaged teeth or other oral problems requiring immediate attention. The resident, admitted with diagnoses including muscle wasting and atrophy, legal blindness, and anemia, reported ongoing dental problems and pain when eating, stating that receiving dental care at the facility was always a big issue. The resident indicated he had seen the dentist only once, had to initiate his own appointments because the facility took a long time, and that scheduled appointments were cancelled at the last minute without explanation. He reported that he mainly ate soft foods to accommodate his discomfort. Record review showed that a dental service note from 08/18/2025 documented a mobile root fragment on tooth #8 causing slight discomfort, with the resident interested in extraction. Despite this, there was no documentation in the resident’s progress notes of tooth pain, a broken tooth, or any follow-up regarding dental services, and the MDS oral/dental section did not reflect mouth or facial pain, chewing difficulty, or broken teeth. Social Services progress notes contained no documentation of offering dental services or any rationale for the lack of access to dental care. The Social Services Director later acknowledged that the resident had been seen by an in-house dentist on 08/18/2025 for the root fragment and that the dental company had been on-site again on 02/27/2026, but the resident was not seen and there was no explanation for the lack of follow-up after the initial visit.
Plan Of Correction
The statements made in this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations, the Center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the Center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 was immediately assessed for further dental needs or concerns on 3/27/2026 by LPN, Unit Manager. Pain assessment completed for resident # 1 with no complaints of dental pain at the time assessment was completed on 3/27/2026 by LPN, Unit Manager. On 3/26/2026 a dental appointment was immediately scheduled by Social Services Director for 4/10/2026 for evaluation and treatment of the identified root fragment on tooth #8 with facility dental provider. Review of resident #1s clinical record. Resident is alert and oriented and capable of making own decisions. Resident had no weight loss Per Dietician resident trending weight gain with meal consumption noted at 75-100% and no difficulty chewing or swallowingPain evaluation for last six months resident noted to have no complaints of pain by resident 2. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken. A facility wide quality review audit was initiated on 3/27/2026 by social services for long term care residents residing in the facility to identify those residents with dental concerns or needs.All identified residents with dental needs will be referred to dental services and scheduled for evaluation and treatment as indicted, as appropriate. 3. What measures will be put into place or what systematic changes you will make to ensure the deficient practiceOn 3/27/2026 The Social Service Director and Social Services Assistant was educated by NH/designee on the components of this regulation with emphasis on ensuring that residents with dental issues or concerns receive dental referrals and evaluation and treatment as indicated.New residents upon admission will be assessed for dental services and residents residing in the facility with identified dental issues/ concerns will be seen by dental services and any follow-up needed will be addressed.MDS Accuracy: The MDS coordinator was re-educated to ensure section L (Oral/Dental status) accurately reflects resident condition based on assessments and resident reports. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into placeThe NHA/ Designee will audit 10 residents weekly x 4 weeks, twice monthly x1 month; then monthly and as indicated until substantial compliance has been met on the following: Ensuring that any identified resident with dental issues or concerns will be seen by the dental services and any follow-up needed will be addressed. Information will be brought to QAPI monthly and monitored until substantial compliance has been met.
Infection Control Deficiencies in Sanitation, Staff Grooming, and Hand Hygiene
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices within the facility. In two resident rooms, improper storage and disposal of toileting items were observed: a plastic urinal was left open on the floor under a bed with a wet area present, and an adult brief with visible soiling was found on the bathroom floor in front of the toilet. These observations were supported by photographic evidence. Additionally, three staff members, including two RNs and one CNA, were observed with artificial nails longer than the facility's policy limit of 1/4 inch, in violation of the dress code and infection control standards. During a meal service, a CNA was observed serving multiple meal trays and assisting a resident with feeding without performing hand hygiene at any point. The CNA was also seen coughing into her hand and wiping her face, then using the same hand to feed a resident, again without hand hygiene. Interviews with facility leadership confirmed that these actions were not in line with facility policy, which requires hand hygiene when entering or exiting resident rooms, between resident care activities, and specifically while feeding residents.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
Two residents were observed in situations that failed to maintain their dignity and privacy as required by facility policy. One resident, with severe cognitive impairment and multiple diagnoses including Parkinson's disease and dementia, was seen from the hallway sitting on the side of his bed, sleeping, and wearing only a T-shirt and a brief, with his brief visible from the hallway. Another resident, who had moderate cognitive impairment and required substantial assistance with dressing, was observed in her wheelchair with her nightgown pulled up and her briefs exposed, also visible from the hallway. Interviews with staff, including CNAs and the DON, confirmed that residents should not be visible in their briefs from the hallway and that maintaining resident privacy is part of their dignity training. The facility's policy emphasizes the importance of protecting and promoting resident rights, including maintaining privacy. Despite this, both residents were left exposed in a manner that did not uphold their dignity, as observed by surveyors.
Failure to Maintain Homelike and Safe Environment in Resident Rooms and Shower Area
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in several rooms and a shower area. During a facility tour, surveyors observed multiple deficiencies: pictures hanging off the wall over a resident's bed, a high-rise toilet seat with dirty tape attached in a resident's bathroom, and torn, unfinished drywall behind a resident's bed. Additionally, one of two shower rooms was being used to store a bed, walker, and reclining chairs, rather than being maintained for resident use. Interviews with staff revealed a lack of awareness and reporting regarding these environmental issues. The RN/Unit Manager was not aware of the specific deficiencies and stated that such issues should have been reported during daily room rounds. The Director of Maintenance also indicated he was unaware of the problems and expected staff to report them through the maintenance system. The Nursing Home Administrator confirmed that managers are assigned to monitor rooms and report concerns, but acknowledged that these issues were not reported as expected. The facility's policy requires housekeeping and maintenance to maintain a sanitary and comfortable environment and for unresolved concerns to be reported to the Administrator.
Failure to Report Resident-to-Resident Incident Resulting in Injury
Penalty
Summary
The facility failed to report an alleged resident-to-resident incident to the appropriate state agencies as required by law. A resident with severe cognitive impairment and multiple diagnoses, including anoxic brain damage and aphasia, was observed with significant bruising and swelling around her left eye. Documentation and staff interviews revealed that another resident mistakenly entered her bed, resulting in physical contact between the two residents' heads. The incident was witnessed by staff, and both residents were assessed, with the affected resident later showing visible injury. The incident was documented in progress notes and communicated to the families of both residents. Despite the presence of injury and the facility's own policy identifying physical marks as possible indicators of abuse, the DON and NHA did not report the incident to state agencies or law enforcement. The DON stated that the event was not considered reportable because there was no intent or physical aggression involved. This decision was made even though the facility's policy requires reporting all alleged violations, including those resulting in injury, within specified time frames.
Failure to Update PASRR Assessments for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASRR) assessments were properly updated for two residents with mental health diagnoses. For one resident admitted with unspecified dementia, mood disorder, major depressive disorder, and insomnia, the Level I PASRR indicated no suspicion of serious mental illness or intellectual disability, and a Level II PASRR was not completed, despite the presence of secondary mental health diagnoses. Similarly, another resident admitted with unspecified dementia, mood disorder, major depressive disorder, and generalized anxiety disorder had a Level I PASRR that did not trigger a Level II evaluation, even though the resident had a primary diagnosis of dementia and additional mental health conditions. Interviews and record reviews revealed that the Social Services Director was responsible for reviewing diagnoses and completing PASRR screenings but was not familiar with the specific regulatory requirements. The process relied on information from psychiatry and GDR meetings to identify new diagnoses, but there was a lack of understanding regarding when a Level II PASRR was required. The facility's policy stated that all applicants should be screened according to state Medicaid rules, with the Social Services Director responsible for tracking PASRR status, but this was not consistently followed, leading to the deficiency.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered, comprehensive care plans that addressed the medical, physical, mental, and psychosocial needs of three residents with severe cognitive impairment. For one resident with Parkinson's Disease and a history of frequent falls, observations revealed repeated unsafe situations, such as being left unsupervised in a high bed with cluttered surroundings and having multiple falls since admission. The care plan included several interventions, but staff interviews indicated a lack of awareness and understanding of these interventions, with some staff unable to access or describe the care plan. Despite ongoing falls, there was no evidence that the effectiveness of interventions was evaluated or that staff were consistently informed of changes. Another resident with anoxic brain damage and aphasia was observed with significant facial bruising, but the care plan did not include any focus, goals, or interventions related to the injury or its monitoring. Staff interviews revealed that the incident was known among staff, but there was no documentation in the care plan to address the injury or prevent recurrence. The lack of care plan updates following significant changes in the resident's condition demonstrated a failure to ensure comprehensive and responsive care planning. A third resident with severe cognitive impairment and behavioral issues had a care plan that addressed a single aggressive incident but did not include additional focuses, goals, or interventions for subsequent behavioral episodes, such as confusion and entering another resident's bed. Staff responsible for updating care plans relied on daily order reports and verbal communication, but there was no systematic process to ensure all relevant staff were informed of care plan changes. The facility's policy required measurable objectives and timely updates, but interviews and documentation showed these requirements were not consistently met.
Failure to Provide Assistance with ADLs: Bathing and Grooming
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents. One resident, admitted with multiple diagnoses including neuromuscular dysfunction and multiple sclerosis, was observed with long white facial hair and expressed a desire for help with its removal. Her records indicated she required supervision or assistance for oral hygiene and was dependent on staff for bathing. A CNA confirmed she had not offered assistance with facial hair removal, and the DON stated that staff should offer help with unwanted facial hair during showers or baths. Another resident, dependent on staff for bathing due to muscle wasting and immunodeficiency, was noted to have a foul odor emanating from his side of the room. Staff discussed not providing a shower due to concerns about covering his neck, and documentation showed that bathing was missed on four out of five opportunities. The resident's care plan indicated a preference for showers with one-person assistance, but records showed refusals were not consistently documented or signed by nursing staff. Facility policy required provision of ADL care based on assessment and resident needs, including bathing and grooming, but these services were not consistently provided or documented for the residents involved.
Failure to Schedule Specialist Appointments and Timely Medication Administration
Penalty
Summary
The facility failed to provide appropriate nursing care and services for several residents, as evidenced by missed specialist appointments and delayed medication administration. One resident with a history of cerebral infarction, benign prostatic hyperplasia, mood disorder, major depressive disorder, and dementia was not scheduled for a stat urology consult as ordered, and there was no evidence of follow-up for an MRI with sedation as requested by the family and recommended by the neurologist. Multiple interviews with staff revealed a lack of awareness regarding the need for these appointments, and the transportation coordinator was not informed of the required consults. The Director of Nursing acknowledged that insurance issues may have contributed to the delay, but this was not documented in the resident's chart, and there was no facility policy available for review regarding appointment scheduling. Additionally, two residents did not receive their medications within the required time frame. One resident with chronic obstructive pulmonary disease, diabetes mellitus, and hypokalemia had multiple medications, including antihypertensives, diuretics, steroids, and inhalers, administered several hours after the scheduled time. Another resident with Parkinson's disease, mood disorder, anemia, major depressive disorder, and neurocognitive disorder with Lewy bodies received gabapentin for pain significantly later than scheduled. Staff interviews confirmed that late medication administration was a recurring issue, attributed to staffing challenges and difficulties locating residents at the time of medication pass. The facility's medication administration policy requires medications to be given within 60 minutes before or after the scheduled time unless otherwise ordered by a physician. Despite this, audit reports and staff interviews confirmed that medications were routinely administered outside of this window. The Director of Nursing stated that late medication administration is not acceptable and that nurses should receive assistance if they are unable to complete medication passes on time.
Failure to Monitor Side Effects of Psychotropic Medications
Penalty
Summary
A deficiency was identified when the facility failed to ensure that side effect monitoring was in place for a resident receiving multiple psychotropic medications. The resident, who had diagnoses including dementia, psychotic disorder with delusions, mood disorder, major depressive disorder, and generalized anxiety disorder, was prescribed Divalproex Sodium, Olanzapine, Lasix, Potassium Chloride, and Hydralazine. Review of the resident's records showed that behavior and antipsychotic side effect monitoring were discontinued on 06/10/25, despite ongoing use of these medications. The care plan indicated that staff should monitor and document for side effects and effectiveness, but there was no evidence of continued side effect monitoring after the specified discontinue date. During an interview, the DON confirmed that side effect monitoring should be documented in the medical record and that the admitting nurse is responsible for entering this information. The facility's medication administration policy also requires staff to report and document adverse side effects. However, the lack of ongoing documentation for side effect monitoring for this resident demonstrated noncompliance with both facility policy and regulatory requirements for unnecessary medications.
Medication Error Rate Exceeds 5% Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5.00%, as evidenced by two errors identified out of twenty-eight medication administration opportunities, resulting in a 7.14% error rate. During observation, a registered nurse dispensed medications for a resident, including Losartan, Lidocaine patch, Zonisamide, Nifedipine, and MiraLAX. The nurse placed a Losartan tablet and an unspecified amount of MiraLAX powder into the same medicine cup, then transferred both into a larger drinking cup. An additional Losartan tablet was dispensed separately, and other medications were added to the cup. Before administration, the process was stopped when it was noticed that an extra Losartan tablet had been mixed with the MiraLAX, and the nurse removed the tablet with a spoon, acknowledging the error. A review of the resident's medication orders showed that only one Losartan tablet and one packet of MiraLAX were to be administered daily. The nurse's method of measuring MiraLAX was inconsistent with the order, as she used an estimated capful rather than a specified packet, and mixed it with other medications, contrary to facility policy and the DON's expectations. The facility's policy required verification of medication name, form, dose, route, and time against the MAR, which was not followed in this instance.
Improper Food Storage and Expired Food Found in Kitchen Areas
Penalty
Summary
Surveyors observed multiple instances of improper food storage and the presence of expired and deteriorating food items in the facility's kitchen areas. In the walk-in freezer, there were several boxes of food, containers, and a bag of ice, along with unidentifiable debris, despite the freezer not being in use due to a malfunctioning door. The walk-in fridge contained a box with a bottle of green liquid, a yellow rag, wrinkled green bell peppers with gray and black bio growth, an open can, a box of tomatoes with yellow string particles, a container of boiled eggs with ripped plastic wrap, and a bucket of pickles labeled with an expiration date that had already passed. The trailer freezer was also found to have multiple open cardboard boxes stacked on top of each other. Interviews with the Certified Dietary Manager (CDM) confirmed that the walk-in freezer was not supposed to be used and that food items had been improperly stored there. The CDM acknowledged that staff may have placed food in the freezer out of convenience, and that expired or poor condition food should have been discarded. The Nursing Home Administrator, upon reviewing photographic evidence, stated an expectation for proper food storage and cleanliness. The facility's own policy requires regular sanitation inspections to ensure compliance with state and federal regulations, which was not followed in these instances.
Failure to Prevent Elopement and Neglect of Residents at Risk
Penalty
Summary
The facility failed to protect two residents identified as being at risk for elopement from neglect, resulting in serious harm to one resident. One resident, with severe cognitive impairment and multiple psychiatric and neurological diagnoses, was able to leave the facility unnoticed. This resident exited through a screened patio door, after removing part of the screen, and walked unsupervised for eight miles along high-traffic streets, eventually being found by the State Highway Patrol on an interstate highway. The resident was subsequently hospitalized for dehydration and acute kidney injury. Interviews and records revealed that the resident was known to wander, had a history of impulsivity and agitation, and was assessed as an elopement risk, but was allowed unsupervised access to an unsecured patio area. Staff were unaware of the resident's whereabouts for an extended period, and there was a delay in notifying law enforcement after the resident was discovered missing. Another resident, also with severe cognitive impairment and a history of wandering, was able to exit the facility through an emergency exit door. The alarm on the door was triggered, and the resident was found 10-15 feet from the building, attempting to leave. This incident was identified as an isolated event by the facility, but it demonstrated a failure to provide adequate supervision and secure the environment for residents at risk of elopement. Both residents had care plans indicating their elopement risk and interventions such as allowing safe wandering on secure units, but these interventions were not effectively implemented. Facility policies required the identification, assessment, and monitoring of residents at risk for elopement, as well as the maintenance and inspection of exit doors and alarms. However, the report documents lapses in staff supervision, communication, and adherence to protocols, including delayed notification of police and failure to secure areas accessible to high-risk residents. These failures resulted in one resident suffering serious harm and created the likelihood of serious injury or death.
Failure to Implement Effective QAPI Plan to Prevent Resident Elopement
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) plan to prevent elopement among residents identified as at risk. One resident with severe cognitive impairment and a history of wandering was able to exit the facility through a door with an alarm, which was heard by staff after the resident had already left the building. The resident was found ambulating away from the facility and stated an intention to leave. The medical director was not familiar with the resident and did not consider the incident to be an elopement, and there was no indication of heightened concern about resident supervision from leadership at that time. Another resident, also with severe cognitive impairment and multiple medical diagnoses, was able to leave the facility unnoticed, walk a significant distance along high-traffic streets, and was eventually found on an interstate highway by law enforcement. This resident was admitted to a higher level of care for evaluation and treatment of dehydration. Staff interviews revealed that the resident was known to walk throughout the building and sit in the patio area, which was previously left unlocked and unsupervised. On the day of the incident, the resident was last seen in the dining room, and staff searched for an extended period before notifying police. The resident exited through a patio screen door by removing part of the screen, which was later found damaged. Facility policies required regular assessment and supervision of residents at risk for elopement, as well as functioning door alarms and prompt staff response to alarms. However, staff interviews and documentation indicated lapses in supervision, communication, and timely response to a missing resident. The facility's QAPI committee did not have an effective plan in place to prevent these incidents, and there was a lack of clear documentation of a comprehensive QAPI policy at the time of the survey.
Failure to Address Flooring Hazards Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate and appropriate protective and support services to prevent accident hazards, resulting in an injury to a resident in the memory care unit. Specifically, the facility did not replace a clean-out drain located in a high-traffic area and failed to address flooring issues promptly and effectively, creating an unsafe walkway. This negligence led to a resident sustaining an injury that required transfer to a higher level of care and surgical intervention. The resident involved had a history of difficulty walking and was independent in some activities of daily living but required supervision for others. The incident occurred near the nursing station and outside the resident's room, where the flooring was uneven due to a concrete patch left by plumbers. The Director of Maintenance (DOM) acknowledged the issue but delayed repairs, attempting temporary fixes that proved inadequate. This resulted in a significant decline in the resident's ability to ambulate and perform daily activities at their prior functional level.
Plan Of Correction
Immediate action(s) taken for the resident(s) found to have been affected include: Flooring was repaired to prevent further accidents. Resident # 6 is no longer resides in the facility. Identification of other residents having the potential to be affected: NHA and Director of Maintenance performed rounds of the facility to identify any hazardous areas. Identified hazards removed and/or repaired. Actions taken/ systems put in place to reduce the risk of future occurrence include: DCS/Designee provided education on Accidents and Supervision policy, redirecting residents with from environmental hazards, and recognizing and reporting potential environmental hazards. An additional staff member has been assigned to memory care unit as Hall Monitor to increase supervision. How the corrective action(s) will be monitored to ensure the practice will not reoccur: Administrator/Director of Maintenance/Designee will complete facility assessment rounds to make certain.
Failure to Address Flooring Hazards Leads to Resident Injury
Penalty
Summary
The facility failed to maintain a safe environment for its residents, particularly in the memory care unit, where a clean-out drain in a high-traffic area was not properly repaired. This oversight led to an unsafe walkway, resulting in a resident tripping and suffering a significant injury. The resident, who had a history of difficulty walking and other medical conditions, was ambulating in the hallway when she tripped over the uneven flooring and tape that was not adequately securing the area. This incident caused a significant change in the resident's ability to walk independently and perform activities of daily living, necessitating surgical intervention. The facility's maintenance records revealed that a work order was created to address the missing clean-out cover, but the issue was not resolved promptly. Instead, temporary measures such as placing a metal sheet and tape over the area were used, which proved inadequate. The Director of Maintenance acknowledged the delay in obtaining the necessary materials to fix the problem and admitted to attempting to handle the repair in-house before calling in professional plumbers. This delay in addressing the hazard contributed to the resident's fall and subsequent injury. Interviews with staff members indicated that the area was known to be a hazard, yet it remained unrepaired for an extended period. The staff, including the Director of Nursing and Certified Nursing Assistants, were aware of the incident and the resident's condition post-fall. The facility's failure to promptly and effectively address the flooring issues and provide adequate supervision and assistance devices placed the resident and others at risk for serious injury.
Plan Of Correction
Immediate action(s) taken for the resident(s) found to have been affected include: Flooring was repaired to prevent further accidents. Resident # 6 is no longer resides in the facility. 2. Identification of other residents having the potential to be affected: NHA and Director of Maintenance performed rounds of the facility to identify any hazardous areas. Identified hazards removed and/or repaired. 3. Actions taken/ systems put in place to reduce the risk of future occurrence include: DCS/Designee provided education on Accidents and Supervision policy, redirecting residents with from environmental hazards, and recognizing and reporting potential environmental hazards. An additional staff member has been assigned to memory care unit as Hall Monitor to increase supervision. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: Administrator/Director of Maintenance/Designee will complete facility assessment rounds to make certain facility is free of hazards once weekly x 8 weeks; then every w weekly x 4 weeks and will continue weekly rounds ongoing. Quality reviews will be completed once a week x8 weeks and then every 2 weeks x1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.
Removal Plan
- Immediate Action: Environmental rounds completed, identified areas of concern noted.
- Summoned Corporate Plant Operations support team for assistance.
- Quality review completed for all current residents sustaining a fall to ensure plan of care is in place, no discrepancies noted.
- Medical Record Review of all residents with falls with major injury conducted: no discrepancies noted.
- 99.5% of all facility staff were educated.
- Initiated and assigned direct care staff member as 'Hallway Safety Monitor' on secure unit for additional supervision.
- Identification of others at risk was accomplished by reassessing all residents residing in the facility for fall risk via Fall Risk Evaluation.
- Facility implemented Activities Invitation Rounds for residents identified at risk for falls.
- The Care Plan Coordinator(s) completed review of care plans to ensure all residents identified as 'at risk' for falls had safety measures, as well as resident specific interventions in place.
- Quality review completed for monitoring of environmental hazards with a focus on uneven surfaces and hazards.
- Identified environmental concerns addressed by priority level, initiated repairs and ongoing.
- Record review of Resident #6 completed.
- Actions to Prevent Occurrence/Recurrence: NHA, DCS, and Plant Operations/Maintenance Director re-educated on ensuring resident environment is free of hazards with emphasis on timely completion.
- Regional DCS educated the DCS on the facility's Fall Prevention Program, all facility related policies, how to conduct an RCA, and how to ensure incident investigations are timely and complete.
- DCS/designee re-educated staff on facility Fall Prevention Program guidelines, following care plan/Kardex interventions, as well as all facility related policies.
- DCS/Designee re-educated staff on Abuse, Neglect, and Exploitation Policy.
- DCS/Designee re-educated staff on Residents' Rights.
- DCS/Designee re-educated staff on Accidents and Supervision Policy.
- DCS/Designee re-educated staff on Recognizing & Reporting Hazards.
- DCS/Designee re-educated staff on Redirecting Residents with Dementia from Environmental Hazards.
- DCS/Designee re-educated staff on securing hazardous areas until plant ops clears, ensuring no harm.
- The Director of Clinical Services/designee to conduct quality monitoring of new admission fall risk evaluation completion to ensure that risk factors, safety measures, and resident specific interventions are reflected on the care plan and Kardex.
- A Performance Improvement Plan (PIP) has been initiated to report on the above monitoring and auditing procedures.
- NHA/Plant Ops/Designee will round to ensure facility is free of hazards.
- DON/designee will review all falls at the clinical meeting with the IDT (interdisciplinary) to ensure appropriate interventions are implemented, the resident's care plan has been reviewed and revised, and the Kardex has been updated.
- Regional DCS will review to ensure a RCA (root cause analysis) has been conducted and that resident specific interventions are reflected in the care plan as well as updated on the Kardex.
- Verification of the facility's removal plan was conducted by the survey team.
Flooring Hazard in Memory Care Unit Leads to Resident Injury
Penalty
Summary
The facility failed to provide a safe environment for residents, staff, and visitors, particularly in the secure memory care unit, where a flooring hazard was present. This hazard was due to an incomplete floor repair in the 200 hallway, which was a high-traffic area. The flooring issue involved a missing clean-out cover that was temporarily covered with a metal sheet and tape, but not properly repaired. This inadequate repair led to a resident tripping and sustaining a serious injury, requiring hospitalization and surgical intervention. The injured resident, who had a history of difficulty walking and other medical conditions, was attempting to detach herself from tape on the floor when she lost her balance and fell. The incident was witnessed by a Certified Nursing Assistant (CNA), who reported that the tape was not holding anything down, and the resident's foot got caught on it. The fall resulted in a significant decline in the resident's ability to ambulate and perform activities of daily living at her prior functional level. The facility's maintenance records showed that the flooring issue was known and documented, but the repair was delayed. The Director of Maintenance (DOM) had attempted temporary fixes and was researching a permanent solution, but the repair was not completed until after the resident's injury. The facility's failure to address the flooring hazard in a timely manner placed other residents, staff, and visitors at risk for serious injury.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Administrator and Director of Maintenance performed environmental rounds, identified areas of concern noted and reported in Electronic Maintenance System. Repairs on all items identified were completed prior to survey exit on Resident # 6 no longer resides in the facility. 2. Identification of other residents having the potential to be affected: Quality review completed for monitoring of environmental hazards with a focus on uneven surfaces and hazards. Administrator/Designee rounded facility to survey for environmental hazards; identified environmental concerns reported via Electronic Maintenance System, addressed by priority level, and completed. 3. Actions taken/systems put in place to reduce the risk of future occurrence include: Administrator/Director of Clinical Services/Maintenance Director re-educated on ensuring resident environment is free of hazards with emphasis on timely completion; Director of Clinical Services/Designee re-educated staff on Accidents and Supervision Policy; Director of Clinical Services/Designee re-educated staff on Recognizing & Reporting Hazards; Director of Clinical Services/Designee re-educated staff on Redirecting Residents from Environmental Hazards; Director of Clinical Services/Designee re-educated staff on securing hazardous areas until plant ops clears, ensuring no harm; initiation and assignment of direct care staff member as Hallway Safety Monitor for secure unit (200 Hall) for additional supervision and hazard identification. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: Administrator/Director of Maintenance/Designee will round to ensure facility is free of hazards twice weekly x 8 weeks; then weekly ongoing. Quality reviews will be completed once a week x 8 weeks and then every 2 weeks x 1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.
Removal Plan
- NHA and Plant Operations Director performed environmental rounds, identified areas of concern, and reported them in the electronic maintenance records system.
- Work orders started in order of priority for hazards causing uneven surfaces, risk hazards, and items with potential to risk resident safety.
- Summoned Corporate Plant Operations support team for assistance.
- Initiated repairs of identified areas of concern.
- Tiles in high traffic area of secure unit (200 Hall) repaired.
- 400 Hall ramp missing carpet tiles replaced with one solid carpet piece.
- Surveyors and NHA completed environmental rounds of the facility noting areas of continued concern.
- List compiled of concerns from environmental tour, all items entered in the electronic maintenance records system.
- 300 Hall clean out with uneven surface repaired.
- 99.5% of all facility staff were educated.
- Initiated and assigned direct care staff member as 'Hallway Safety Monitor' on secure unit (200 Hall) for additional supervision.
- Quality review completed for monitoring of environmental hazards with a focus on uneven surfaces and hazards.
- NHA/Designee rounded facility to survey for environmental hazards.
- Identified environmental concerns reported via electronic maintenance records system, addressed by priority level, and repairs initiated and will be ongoing.
- NHA, DCS, and Plant Operations/Maintenance Director re-educated on ensuring resident environment is free of hazards with emphasis on timely completion.
- DCS/Designee re-educated staff on Accidents and Supervision Policy.
- DCS/Designee re-educated staff on Recognizing & Reporting Hazards.
- DCS/Designee re-educated staff on Redirecting Residents with from Environmental Hazards.
- DCS/Designee re-educated staff on securing hazardous areas until plant ops clears, ensuring no harm.
- Initiation and Assignment of direct care staff member as 'Hallway Safety Monitor' for secure unit (200 Hall) for additional supervision and hazard identification.
- A Performance Improvement Plan (PIP) has been initiated to report on the above monitoring and auditing procedures.
- NHA/Plant Ops/Designee will round to ensure facility is free of hazards; then twice weekly; then weekly and PRN (as needed) as indicated.
- These audits will be submitted to the Quality Assurance Performance Improvement (QAPI) Committee by the assigned auditors.
Unauthorized Social Media Posts Violate Resident Privacy
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by unauthorized videos of residents being posted on social media platforms. These videos, which included residents dancing or appearing in the background, were recorded by a staff member, the Admissions Coordinator, without obtaining consent from the residents or their legal representatives. The videos were shared widely, garnering significant views and interactions online, which violated the residents' rights to privacy and confidentiality. The report highlights that 10 out of 16 sampled residents were affected by this breach of privacy. Many of these residents resided in the secure memory care unit and had diagnoses that impaired their ability to provide informed consent. For instance, Resident #10, who was featured in the videos, had been diagnosed with conditions affecting her cognitive abilities, and her admission record indicated she was unable to make willful and knowing health decisions. Similarly, Resident #14's Health Care Surrogate confirmed that no consent was given for the social media postings, and Resident #13's records showed she was incapable of communicating health decisions. Interviews with facility staff, including the Nursing Home Administrator and the Regional Nurse Consultant, revealed that the videos were discovered inadvertently through social media. The staff involved did not inform the administration about the recordings, and it was only after the videos were identified online that the issue was addressed. The facility's policy on social media use explicitly prohibits unauthorized recordings and postings, yet this policy was not adhered to, leading to the violation of residents' rights.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Facility contacted residents responsible parties/representatives/families of residents #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16 to notify them that the residents were posted on social media by a staff member, without the facility's knowledge. Staff members were advised to remove all resident-related content from social media. All videos found were reported to the social media to remove videos. The legal department at Tik Tok was contacted to remove videos. Staff member was terminated. 2. Identification of other residents having the potential to be affected: Multiple social media platforms reviewed to identify any postings of facility residents. Facility-wide audit of all residents currently residing in the facility to verify photo consents are signed and present in the medical record. The photo consent form. Quality reviews will be completed once a week x8 weeks and then every 2 weeks x1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.
Breach of Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to ensure personal privacy and confidentiality for ten of sixteen sampled residents, as evidenced by videos posted on social media platforms without consent. These videos, which included residents dancing or appearing in the background, were recorded in various locations within the facility, including the secure memory care unit and hallways. The videos were originally posted by the Admissions Coordinator and subsequently reposted and edited by unknown users, leading to widespread dissemination across social media platforms. Several residents involved in the videos had severe cognitive impairments, as indicated by their medical records and assessments. For instance, one resident had a severe cognitive impairment score and was unable to communicate a willful and knowing health decision. Family members of these residents were not informed or asked for consent prior to the posting of the videos. Interviews with family members revealed that they were unaware of the social media postings and would not have consented to their loved ones being featured in such videos. The facility's policy on social media use explicitly prohibits the unauthorized taking, keeping, or distributing of photographs or recordings of residents, emphasizing the need to maintain resident privacy and confidentiality. Despite this policy, the Nursing Home Administrator and Regional Nurse Consultant were unaware of the videos until they were brought to their attention. The Admissions Coordinator, who was responsible for the original postings, was identified and subsequently suspended, with plans for termination. This incident highlights a significant breach of privacy and confidentiality protocols within the facility.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Facility contacted residents responsible parties/representatives/families of residents #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16 to notify them that the residents were posted on social media by a staff member, without the facility's knowledge. Staff members were advised to remove all resident-related content from social media. All videos found were reported to the social media to remove videos. The legal department at Tik Tok was contacted to remove videos. Staff member was terminated. 2. Identification of other residents having the potential to be affected: Multiple social media platforms reviewed to identify any postings of facility residents. Facility-wide audit of all residents currently residing in the facility to verify photo consents are signed and present in the medical record. The photo consent form was revamped to include social media posting. The consent form does not permit staff to post on their personal pages. The consent clearly states for use on Lakeland Nursing and Rehab OPCO, LLC's official social media accounts. 3. Actions taken/systems put in place to reduce the risk of future occurrence include: RDCS/DCS/Designee re-educated staff on facility policies to include Neglect, Resident Rights, Social Media, and Personal Cell Phone Use. NHA has since created an official social media page for authorized facility-related content and is the authorized administrator of the page. Resident records will be reviewed for photo and social media consent prior to any posting of content. No phones are allowed to be out in patient care areas. Nursing Home Administrator/Designee will search social media weekly for postings related to our facility. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Admissions Director/Designee will conduct an audit of new admission records to make certain records contain Photo Consent Form five times a week for 4 weeks, 3 times a week for 4 weeks, twice weekly for 4 weeks, then weekly and PRN as indicated. The Administrator/Designee will conduct reviews of social media (Tik Tok, Facebook, Instagram) weekly for 8 weeks and every 2 weeks for 1 month, then monthly for 3 months and quarterly or PRN as indicated. Quality reviews will be completed once a week for 8 weeks and then every 2 weeks for 1 month. Quality reviews will be reviewed by the QAPI committee monthly for 3 months or until substantial compliance is met along with quarterly reviews.
Missing Admission Paperwork for Residents
Penalty
Summary
The facility failed to ensure that admission paperwork, including admission agreements and consents, was present in the resident records for four of the sixteen sampled residents. During a review of the records for these residents, it was found that there was no documentation of the necessary admission paperwork, which includes admission consents and admission agreements/contracts. The deficiency was confirmed by the Administrator, who acknowledged that the admission paperwork for these four residents could not be located. The Administrator expressed uncertainty about what happened to the documents and indicated that the facility was in the process of obtaining new admission paperwork for the affected residents.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Facility contacted resident/representative and obtained new admission agreement for residents #7, #9, #11 and #15. 2. Identification of other residents having the potential to be affected: A facility wide audit was completed for all in-house residents. Review of medical records to verify and ensure admissions agreements were completed for all residents. Any resident found not to have an agreement was completed. 3. Actions taken/ systems put in place to reduce the risk of future occurrence include: Admissions department staff were educated to ensure admission agreements are completed and signed in a timely manner. Audits will be put in place. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Director of Admissions/designee will conduct quality review of resident records to ensure admission agreements are completed and uploaded into resident records. Records of newly admitted residents will be monitored for Admission agreements completion and upload. Quality reviews will be completed once a week x8 weeks and then every 2 weeks x1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.
Deficiency in Accurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure accurate and complete documentation for a resident, leading to a deficiency in maintaining medical records. The resident, who had been admitted with diagnoses including idiopathic conditions, acute failure, and dependence on supplemental support, experienced a change in condition related to decreased food and fluid intake. Despite the situation being assessed and the provider being notified, the clinical record did not accurately reflect the events that transpired, including the initiation of emergency procedures and the calling of Emergency Medical Transport (EMT). The Director of Nursing (DON) confirmed that the clinical record and transfer form did not document the emergency intervention that was administered. The facility's policy on documentation requires that each resident's medical record accurately represent their experiences and include timely and complete information. However, in this case, the documentation was not completed in accordance with the facility's policy, as it failed to capture the critical interventions and notifications made during the resident's change in condition.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Review of resident #4s clinical record. Resident #4 was transferred out to Lakeland Regional Medical Center. Upon record review resident #4 was transferred out and expired, therefore, she no longer resides at Lakeland Nursing and Rehab. Late entry regarding the event was input in Resident #4s clinical record. 2. Identification of other residents having the potential to be affected: Quality review of code blue events to ensure record contains documentation of per advance directive order. Review of code blue events for the past 90 days to ensure change of condition, transfer forms, if applicable, MD notification, and resident representative notification. 3. Actions taken/ systems put in place to reduce the risk of future occurrence include: Director of Clinical Services reeducated on documentation policy. All licensed nurses educated on proper documentation protocols, code blue events, change of condition and transfer forms. Code blue events, change of conditions, and transfer forms will be reviewed in the morning clinical meeting with follow-up as necessary. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Director of Nursing/ Designee to complete quality review of any code blue event to make certain record reflects proper documentation. Audits of code blue events, change of condition, transfer forms, if applicable, MD notification, and resident representative notification. Quality reviews will be completed once a week x8 weeks and then every 2 weeks x1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.
Failure to Report Neglect and Ensure Safe Environment
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident who suffered a major injury due to an unsafe environment. The incident involved a resident in the memory care unit who experienced an unwitnessed fall in the hallway, resulting in a significant injury that required surgical intervention. The facility's policy mandates immediate reporting of such incidents, especially when they involve serious bodily injury, but this was not adhered to. The resident, who had a history of poor safety awareness and was residing in the memory care unit, tripped and fell in a hallway with rough and uneven concrete. This area was a known high-traffic zone and had a raised drain cap, which posed a hazard. Despite the known risk, the facility did not take timely action to repair the flooring hazard, which contributed to the resident's fall and subsequent injury. Interviews with facility staff, including the Director of Nursing and the Director of Maintenance, revealed a lack of prompt reporting and inadequate measures to ensure a safe environment. The Director of Nursing did not report the incident, believing the plan of care was followed, while the Director of Maintenance acknowledged the flooring issue but only addressed it after the incident occurred. The facility's failure to report the incident and address the environmental hazard in a timely manner led to the deficiency.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Nursing Home Administrator/Coordinator re-educated on ensuring that allegations of neglect or mistreatment are reported according to federal guidelines time frame. Late report completed for Resident # 6. Resident #6 no longer resides at the facility. 2. Identification of other residents having the potential to be affected: Care Plan Coordinator/Designee completed quality review of residents who sustained in past 6 months. No newly affected residents identified. 3. Actions taken/ systems put in place to reduce the risk of future occurrence include: Education for all staff on Neglect and a position has been created for a facility risk manager, and we are currently recruiting for the position. A daily Risk Management Meeting initiated at daily clinical meeting, to include attendance of the interdisciplinary team with NHA oversight. Risk events including alleged violations involving possible neglect, mistreatment, injuries of unknown source and misappropriation will be reviewed by Administrator/Risk Manager/Designee to ensure all reportable events meet the time frame guidelines for reporting. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Administrator/Risk Manager/Designee will conduct an audit of risk events to monitor all risk events for alleged violations including possible neglect, mistreatment, injuries of unknown source and misappropriation and make certain violations are reported five times a week X 4 weeks, 3 times a week X 4 weeks, twice weekly X 4 weeks, then weekly and as indicated. Quality reviews will be completed once a week x8 weeks and then every 2 weeks x1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.
Failure to Report Allegation of Neglect and Maintain Safe Environment
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident who suffered a major injury due to an unsafe environment. The incident involved a resident in the memory care unit who was ambulating in the hallway and experienced a fall, resulting in a significant injury that required surgical intervention. The resident's care plan indicated a risk for falls due to poor safety awareness and other factors, yet the environment was not maintained free of hazards, contributing to the incident. The investigation revealed that the resident tripped in a high-traffic area with rough and uneven concrete, which had a raised drain cap. This area was located near the dining room, nurses' station, and the resident's room. Despite being a known hazard, the facility did not adequately address the flooring issue in a timely manner. The Director of Maintenance had attempted temporary fixes, but the area remained a risk, and the facility's response was insufficient to prevent the incident. Interviews with staff indicated that the incident was not reported as an adverse event because the plan of care was followed, despite the resident suffering a significant change in condition. The facility's policy required immediate reporting of such incidents, but this was not adhered to. The Director of Nursing and other staff members were aware of the incident but failed to report it to the appropriate authorities within the required timeframe.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Nursing Home Administrator/Coordinator re-educated on ensuring that allegations of neglect or mistreatment are reported according to federal guidelines time frame. Late report completed for Resident # 6. Resident #6 no longer resides at the facility. 2. Identification of other residents having the potential to be affected: Care Plan Coordinator/Designee completed quality review of residents who sustained in past 6 months. No newly affected residents identified. 3. Actions taken/ systems put in place to reduce the risk of future occurrence include: Education for all staff on Neglect and a position has been created for a facility risk manager, and we are currently recruiting for the position. A daily Risk Management Meeting initiated at daily clinical meeting, to include attendance of the Interdisciplinary team with NHA oversight. Risk events including alleged violations involving possible neglect, mistreatment, injuries of unknown source and misappropriation will be reviewed by Administrator/Risk Manager/Designee to ensure all reportable events meet the time frame guidelines for reporting. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Administrator/Risk Manager/Designee will conduct an audit of risk events to monitor all risk events for alleged violations including possible neglect, mistreatment, injuries of unknown source and misappropriation and make certain violations are reported five times a week X 4 weeks, 3 times a week X 4 weeks, twice weekly X 4 weeks, then weekly and as indicated. Quality reviews will be completed once a week x8 weeks and then every 2 weeks x1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.
Incomplete Documentation of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure accurate and complete documentation for a resident who experienced a change in condition. The resident, who had been admitted with diagnoses including idiopathic acute failure and dependence on supplemental support, was found unresponsive after being transferred to another room. Despite the emergency medical transport being called and the physician and family being notified, the clinical record and transfer form did not document that emergency measures were initiated. An interview with the Director of Nursing (DON) revealed that the expectation was for staff to document the initiation of emergency measures and the calling of EMTs in the clinical record. However, the DON confirmed that this documentation was missing. The facility's policy on medical record documentation requires that each resident's medical record accurately represent their experiences and include timely documentation of assessments, observations, and services provided. This policy was not adhered to in this instance, leading to incomplete documentation of the resident's care during a critical event.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Review of resident #4s clinical record. Resident #4 was transferred out to Lakeland Regional Medical Center. Upon record review resident #4 was transferred out and expired, therefore, she no longer resides at Lakeland Nursing and Rehab. Late entry regarding the event was input in Resident #4s clinical record. 2. Identification of other residents having the potential to be affected: Quality review of code blue events to ensure record contains documentation of per advance directive order. Review of code blue events for the past 90 days to ensure change of condition, transfer forms, if applicable, MD notification, and resident representative notification. 3. Actions taken/ systems put in place to reduce the risk of future occurrence include: Director of Clinical Services reeducated on documentation policy. All licensed nurses educated on proper documentation protocols, code blue events, change of condition and transfer forms. Code blue events, change of conditions, and transfer forms will be reviewed in the morning clinical meeting with follow-up as necessary. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Director of Nursing/ Designee to complete quality review of any code blue event to make certain record reflects proper documentation. Audits of code blue events, change of condition, transfer forms, if applicable, MD notification, and resident representative notification. Quality reviews will be completed once a week x8 weeks and then every 2 weeks x1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records for a resident whose family had requested them. The resident, who had been admitted with conditions including Alzheimer's disease, peripheral vascular disease, heart disease, and edema, had their medical records requested by a family member on July 28, 2023. The Medical Records Director (MRD) acknowledged the request but delayed fulfilling it due to instructions from the new company that acquired the facility in June 2023. The MRD was told to hold off on legal cases and sending charts, pending contact with company attorneys, which the facility did not have at the time. Despite communication with the family member, the MRD did not release the records, citing the absence of a response from the family's attorney since October 2023. The facility's policy on the release of information, revised in November 2009, states that residents or their legal representatives can access their medical records upon written consent. The policy also specifies that records should be accessible within a certain number of hours and that photocopies can be obtained with 48 hours' notice, excluding weekends and holidays. However, the MRD admitted that the request made by the resident's Power of Attorney for clinical summaries, lab and diagnostics, and the entire medical record had not been fulfilled approximately 11 months after the initial request. This failure to provide the requested records in a timely manner constitutes a deficiency in the facility's compliance with its own policies and regulatory requirements.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory tests were completed for a resident who had undergone a renal transplant. The resident was informed by the provider that blood work was to be done, but it had not been completed. The resident was supposed to have weekly Creatinine levels checked and avoid nephrotoxic agents, including diuretics, as per the provider's notes. Additionally, the provider planned for Vitamin B12/Folate levels to be checked with the next blood draw, but these orders were not reflected in the laboratory orders. The review of the resident's laboratory results and physician orders showed that several tests, including a Basic Metabolic Panel (BMP) with glomerular filtration rate (GFR), Complete Blood Count (CBC) with differential, Complete Metabolic Panel (CMP), and Magnesium (Mag), were not completed as ordered. The Treatment Administration Record (TAR) indicated that some orders were discontinued while pending confirmation, and the Medication Administration Record (MAR) did not include any laboratory tests. Interviews with staff revealed a lack of awareness and understanding of the process for confirming and entering laboratory orders, contributing to the oversight. The Interim Director of Nursing (DON) and other staff members acknowledged the issue with the laboratory orders not being entered correctly into the system. The facility's policy on laboratory services and reporting emphasized the need for timely provision of laboratory services and prompt notification of results outside the clinical reference range. However, the deficiency in ensuring the completion of physician-ordered laboratory tests for the resident was evident, as the orders were not properly entered or confirmed, leading to missed tests.
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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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