West Delray Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Delray Beach, Florida.
- Location
- 16200 S Jog Road, Delray Beach, Florida 33446
- CMS Provider Number
- 106005
- Inspections on file
- 22
- Latest survey
- June 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at West Delray Nursing & Rehab Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and intact cognition did not have grievances documented or resolved after the resident's son reported concerns about care, medications, and malfunctioning equipment to facility administrators. Despite the facility's policy requiring documentation and follow-up of grievances, staff could not explain the absence of these complaints in the official records.
A resident with multiple chronic conditions was admitted and did not receive several physician-ordered medications for immediate care until the tenth day of their stay. Although recommendations and telephone orders were made at admission, these medications were not documented in the medical record or MAR, and facility staff could not explain the delay.
The facility failed to follow physician orders, resulting in a medication error rate of 32%, affecting multiple residents. The errors were identified during a medication pass observation signed by the Consultant Pharmacist for an LPN, where medications were not administered within the required time frame as per facility policy.
The facility's medication error rate was 32%, exceeding the acceptable threshold of 5%. Errors were observed in the timing of medication administration, with staff overwhelmed by additional duties. Management was aware of the delays, and some staff had attended in-services, but issues persisted.
The facility's QAPI program failed to correct medication errors, with 10 errors observed out of 31 opportunities, affecting four residents. Despite re-education and monitoring efforts, the medication error rate exceeded the acceptable threshold, indicating ineffective implementation of corrective measures.
The facility failed to ensure call lights were within reach for two residents, one with intact cognition and another with severe cognitive impairment. Both residents were at risk for falls, and the call lights were observed out of reach, contrary to care plan interventions and facility policy. A CNA confirmed the importance of keeping call lights accessible and responding promptly.
A facility failed to update a resident's Advanced Directives status, resulting in a deficiency. The resident had a DNR order, but this was not reflected in the physician orders or EHR. Staff interviews revealed inconsistencies in the process of documenting and updating Advanced Directives, contributing to the oversight.
A resident with cognitive impairment and a history of falls was found with significant injuries after an unwitnessed fall. The facility failed to report the incident to the state agency, as required by policy and law. The DON and Administrator did not recognize the fall as reportable, assuming it was due to the resident's behavior. The investigation was incomplete, lacking documentation of corrective actions and follow-up, and staff interviews revealed a lack of understanding of reporting requirements.
A resident with cognitive impairment and multiple diagnoses did not receive wound care as per physician orders, with inconsistencies in dressing changes and documentation. Observations showed outdated dressings, and interviews confirmed lapses in care and communication among staff.
A resident with cognitive impairment and a history of falls did not receive a Fall Risk Assessment upon admission, leading to an unwitnessed fall with significant injuries. The facility failed to document or investigate the incident properly, and there was no evidence of follow-up or reporting to the state. Staff interviews indicated the resident was often confused and attempted to ambulate without assistance, yet interventions were not effectively implemented.
A resident with a history of neurogenic bladder was observed with an unsecured Foley catheter, and improper catheter care was provided by a CNA. The CNA failed to perform hand hygiene, did not provide privacy, and used incorrect cleaning techniques. The catheter tubing was placed under the resident's leg without an anchor, contrary to the care plan. The DON confirmed these deficiencies during an observation.
Two residents experienced significant weight loss that was not addressed in a timely manner, leading to deficiencies in nutritional care. One resident lost 7.10% of their weight over a month, and another lost 18% over two months. Documentation showed inconsistent recording of nutritional supplement intake, with no percentage of consumption noted. Staff interviews revealed limitations in the documentation system, contributing to the deficiencies.
A facility failed to ensure timely physician visits for a resident with severe cognitive impairment. The facility's policy requires monthly visits for the first 90 days and every 60 days thereafter. However, there was no documentation of visits by the attending physician over a three-month period. The physician stated that he alternates visits with an NP, who documents their collaboration, but he does not author any notes himself. The DON acknowledged the lack of documentation.
The facility failed to meet the minimum required nursing and CNA staffing levels for 3 out of 28 days. The CNA daily average fell below 2.0 on two occasions, and the nursing daily average was below 1.0 on two occasions. Interviews with the Staffing Coordinator and DON confirmed the deficiency, particularly on weekends.
The facility failed to post complete nurse staffing information for four days, listing only hours worked without specifying the number of nursing staff or the facility name. Observations showed consistent omissions, and interviews revealed a lack of clarity in the posting process, with the Staffing Coordinator not including staff numbers on the postings.
The facility failed to comply with the 14-day limit for PRN psychotropic medications for three residents, lacking documented rationale for extending orders. A resident with anxiety and depression was prescribed Alprazolam for 30 days without justification. Another resident with Generalized Anxiety Disorder had a PRN order for Lorazepam extended without documentation. A third resident with anxiety and depression received Alprazolam frequently over three months without a documented start or end date. The Consultant Pharmacist and DON confirmed the non-compliance.
The facility's medication error rate was 13.33%, exceeding the acceptable 5% threshold. Two residents experienced medication administration errors, including late administration and improper handling of medications. Staff interviews revealed a lack of understanding of medication administration policies, contributing to the errors.
The facility failed to properly supervise and store medications for two residents, with OTC medications found unattended in their rooms without physician orders or care plans for self-administration. Additionally, medication and treatment carts were left unlocked and unattended by staff, compromising medication security.
The facility failed to meet food safety standards during kitchen inspections, with issues such as improper food storage, inadequate sanitation, and equipment maintenance problems. Observations included undated and expired food items, sanitation buckets with no solution, and a dishwasher not reaching required temperatures.
The facility failed to maintain accurate clinical records for two residents. A resident with Parkinson's Disease did not receive documented wound care as ordered, with discrepancies in dressing dates and no evidence of treatment refusal. Another resident with severe cognitive impairment had medical notes inaccurately listing a Nurse Practitioner as a Physician, with no documented physician visits. These issues highlight deficiencies in documentation and adherence to care protocols.
The facility failed to follow CDC guidelines for infection control, as a CNA used the same gloves for multiple tasks with a resident, and an RN did not disinfect vital signs equipment between uses on two residents. This breach in protocol exposed residents to potential infection risks.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to appropriately respond to and resolve grievances for one resident, as required by its own grievance policy. The policy states that grievances may be voiced verbally to staff and must be documented on the facility grievance report. However, a review of the grievance records for May did not show any documentation of complaints or concerns from the resident's son, despite his statements that he reported multiple issues to both the former and new Administrators. These issues included concerns about medications, falls, a non-functioning bed and TV, and resident rights. The son reported that he did not receive any updates or progress regarding his complaints, and was particularly concerned about medications not being administered until the night before the resident's discharge. The resident involved had multiple diagnoses, including pulmonary hypertension, muscle wasting and atrophy, type 2 diabetes mellitus with peripheral angiopathy, atrial fibrillation, hypothyroidism, and chronic kidney disease. The resident was assessed as having intact mental cognition. Staff interviews revealed that grievances are typically assigned and resolved within a few days, and that maintenance issues are usually addressed promptly. However, the staff member responsible for social services was unable to explain why the resident's grievances were not documented in the report, stating that there were no reported grievances from the resident, despite the son's statements to the contrary.
Delay in Administration of Physician-Ordered Medications Upon Admission
Penalty
Summary
A newly admitted resident with multiple complex diagnoses, including pulmonary hypertension, muscle wasting, diabetes mellitus with peripheral angiopathy, atrial fibrillation, chronic kidney disease, osteoporosis, and hypothyroidism, did not receive physician-ordered medications for immediate care upon admission. The resident was assessed as having intact mental cognition and was admitted with weakness and a recent fall. The Advanced Registered Nurse Practitioner recommended continuation of current medications and fall risk precautions, and the pharmacist reviewed the medication regimen and made recommendations. However, there were no documented physician orders for several recommended medications, including gabapentin, carvedilol, calcitriol, allopurinol, and sodium bicarbonate, at the time of admission. Nursing progress notes indicated that medications were ordered by telephone on the day of admission, but these orders were not reflected in the resident's medical record or Medication Administration Record (MAR) until the tenth day of the resident's stay. During this period, there was a lack of documentation specifying which medications were unavailable or what new orders were implemented. The resident did not receive the recommended medications until the night before a resident-initiated discharge, despite facility staff stating that medications should be started as soon as possible after admission. Facility leadership was unable to provide an explanation for the delay in medication administration.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that physician orders were followed, resulting in a medication error rate of 32%, which is significantly higher than the acceptable threshold of 5%. During observations, interviews, and record reviews, ten medication errors were identified out of 31 opportunities, affecting four residents. The facility's policy on drug administration requires medications to be administered within one hour before or after their prescribed time, but this was not adhered to, leading to the high error rate. The errors were documented during a medication pass observation signed by the Consultant Pharmacist for a Licensed Practical Nurse (LPN).
Plan Of Correction
(1) Actions taken to correct the deficient practice: Resident #2 was evaluated on by the Unit Manager. There have been no ill effects noted from the medication errors. The physician and family were notified. The resident remains at the facility and is stable. Resident #3 was evaluated on by the Unit Manager for any side effects due to medication timing and administration errors and none observed. The physician and resident family were notified. The resident remains at the facility and is stable. Resident #5 was evaluated on by the Unit Manager for any side effects due to medication timing and administration errors and none observed. The physician and resident family were notified. The resident remains at the facility and is stable.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 32%. During medication administration observations, 10 errors were identified out of 31 opportunities, affecting multiple residents. The errors included improper timing of medication administration, with medications being given outside the one-hour window before or after the prescribed time. Staff members, including LPNs, were observed administering medications late, and some staff reported being overwhelmed with additional responsibilities such as skin care, answering call lights, and communicating with families and doctors. Specific instances included a resident receiving a chewable tablet separated from other medications due to its form, and another resident's medication being delayed due to low vital signs. Staff interviews revealed that management was aware of the delays, and some staff had attended medication administration in-services. Despite these efforts, the issue persisted, with staff struggling to manage their time effectively, leading to significant delays in medication administration.
Plan Of Correction
(1) Actions taken to correct the deficient practice: Resident #2 was evaluated on by the Unit Manager. There have been no ill effects noted from the medication errors. The physician and family were notified. The resident remains at the facility and is stable. Resident #3 was evaluated on by the Unit Manager for any side effects due to medication timing and administration errors and none observed. The physician and resident family were notified. The resident remains at the facility and is stable. Resident #5 was evaluated on by the Unit Manager for any side effects due to medication timing and administration errors and none observed. The physician and resident family were notified. The resident remains at the facility and is stable. Resident #6 was evaluated on by the Unit Manager for any side effects due to medication timing and administration errors and none observed. The physician and resident family were notified. The resident remains at the facility and is stable. Staff A received re-education on by ADON on administering medications as per physician orders and notification to supervisor and/or physician if medications may be administered outside of scheduled time frame. Staff B received re-education on by ADON on administering medications as per physician orders and notification to supervisor and/or physician if medications may be administered outside of scheduled time frame. Staff C received re-education on by ADON on administering medications as per physician orders and notification to supervisor and/or physician if medications may be administered outside of scheduled time frame. Staff E received re-education on monitoring the timeliness of medication administration and facility process to follow specific to timeliness of medication.
Medication Errors Persist Despite QAPI Efforts
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) Program failed to effectively address and correct identified quality deficiencies related to medication errors. During a revisit survey, surveyors observed 10 medication errors out of 31 opportunities, affecting four residents. This repeated deficient practice was previously cited during a recertification survey, indicating ongoing issues with medication administration. The Director of Nursing (DON) was informed of the medication administration errors, which were documented under F759, Free of Medication Errors. Despite the facility's plan of correction, which included re-education of licensed nursing staff on the medication administration process, the errors persisted. The facility's QAPI program did not ensure that the medication error rate was maintained below the acceptable threshold of 5%. The facility's survey history and plan of correction records were reviewed, revealing that the Licensed Practical Nurses (LPNs) involved had undergone orientation and medication pass observations. However, these measures were insufficient in preventing the recurrence of medication errors, highlighting a lack of effective implementation and monitoring within the QAPI program.
Plan Of Correction
(1) What corrective actions will be taken for those residents found to have been affected by the deficient practice: AD Hoc QAPI Meeting was held on with the Administrator, Medical Director, Director of Nursing and interdisciplinary team members. The meeting agenda included the components of Regulations: F759 Free of Medication Error rates 5% or more and F867 QAPI and the areas of concerns communicated on survey exit by the Agency for Health Care Administration. (2) How you will identify other residents having the potential to be affected by the same practice and what corrective actions will be taken: The Regional Vice President of Operations re-educated the Administrator on regarding the components of this regulation with emphasis on ensuring quality assurance monitoring of facility processes related Medication Administration. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: QAPI meeting was conducted on and by the Administrator. Participation included interdisciplinary team members as well as the Medical Director. Meeting agenda included the components of Regulations: F-759 Free of Medication Error Rates 5 Percent or more F-867 QAPI. Education was provided by the Administrator to QAPI team members on related to the elements of the Quality Assurance and Process Improvement program and to ensuring quality assurance monitoring of facility processes related to Medication Administration. (4) How the corrective actions will be monitored to ensure the practice will not recur: The facility Administrator/designee will conduct a quality review of QAPI to ensure quality assurance monitoring of medication administration to ensure ordered medications are being administered in a timely manner and as prescribed by the physician weekly x 4 weeks, and then every 2 weeks x 2 months then PRN as indicated. The findings of this quality monitoring will be reported to the QAPI monthly. Quality Monitoring schedule will be modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a deficiency in accommodating their needs and preferences. Resident #8, who was admitted with diagnoses including dizziness and heart disease, had a fall resulting in knee injuries. Despite an updated care plan intervention to keep the call light within reach, it was observed out of reach behind her bed during an interview. Resident #8 confirmed her inability to reach the call light, which was crucial for her to call for assistance due to her fall risk. Similarly, Resident #71, admitted with repeated falls and dementia, was observed with the call light out of reach on two separate occasions. Despite her severe cognitive impairment, she acknowledged the presence of the call light but was unable to reach it. Staff B, a Certified Nursing Assistant, confirmed the importance of keeping the call light accessible and responding promptly, especially for residents at risk of falls. The failure to ensure call lights were within reach for these residents highlights a deficiency in the facility's adherence to its policy and the residents' care plans.
Failure to Update Advanced Directives Status
Penalty
Summary
The facility failed to update the Advanced Directives status for a resident, leading to a deficiency. The resident, who was admitted with conditions including Multiple Sclerosis and Major Depressive Disorder, had a documented Do Not Resuscitate (DNR) order signed by both the physician and the resident. However, this DNR status was not reflected in the physician orders or the resident's Electronic Health Record (EHR) profile in Point Click Care (PCC). The care plan indicated the resident's desire for their Advanced Directives to be honored, but it did not specify the chosen code status. Additionally, there were inconsistencies in the documentation, with some notes indicating a Full Code status despite the resident's DNR order. Interviews with staff revealed a lack of clarity and consistency in the process of documenting and updating Advanced Directives. A Registered Nurse stated that if a DNR order was present, it should be uploaded to the PCC, but this was not done for the resident in question. The Social Worker mentioned that Advanced Directives should be initiated immediately upon admission and included in both the paper chart and EHR, with a physician's order in place within a week. However, this process was not followed, leading to the deficiency. The staff's understanding of the procedures for documenting Advanced Directives was inconsistent, contributing to the oversight.
Failure to Report Unwitnessed Fall with Injury
Penalty
Summary
The facility failed to report a resident's unwitnessed fall with an injury of unknown source, which is a violation of their policy and state law. The resident, who had a history of repeated falls and cognitive impairment, was found on the floor with significant injuries, including a large laceration on the forehead and skin tears on both legs. Despite the severity of the injuries and the resident's inability to explain the cause of the fall, the incident was not reported to the state agency as required. The Director of Nursing (DON) and the Administrator did not recognize the incident as reportable, assuming the fall was due to the resident's behavior of attempting to ambulate without assistance. The facility's investigation into the fall was incomplete, lacking documentation of corrective actions, follow-up, and a comprehensive fall risk assessment. Additionally, there was no evidence of neurologic checks or a fall log to track the resident's falls, which are essential components of the facility's policy. Interviews with staff revealed a lack of awareness and understanding of reporting requirements for falls with injuries of unknown sources. The Administrator believed that only incidents involving abuse or neglect needed to be reported, while the DON was unable to provide a complete investigation or corrective actions. This oversight highlights a significant deficiency in the facility's adherence to reporting protocols and the management of resident safety.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure that Resident #2 received treatment and care in accordance with physician orders for skin conditions. The resident, who was admitted with multiple diagnoses including Parkinson's Disease and cognitive impairment, had specific physician orders for wound care on her knees. These orders included cleansing and dressing changes on specified days. However, the facility's records and observations revealed that these orders were not consistently followed, as evidenced by undated and outdated dressings on the resident's knees. The March 2025 Treatment Administration Record (TAR) for Resident #2 lacked documentation of weekly skin checks and did not show evidence of dressing changes as per the physician's orders. Observations on multiple days showed that the dressings on the resident's knees were not changed according to the schedule, and there was no documentation of the resident refusing care. Interviews with the resident and staff confirmed the inconsistencies in care, with the resident expressing pain and difficulty in movement following a fall, and staff acknowledging the resident's confusion and occasional refusal of care. Further interviews with the Wound Care Nurse and Unit Manager confirmed that the dressing changes were not performed as ordered, and there was a lack of communication and documentation regarding the resident's care. The Wound Care Nurse admitted to performing a dressing change on a day not scheduled by the physician's orders, and the Unit Manager acknowledged the discrepancies in the TAR and the lack of progress notes regarding the resident's refusal of care. These failures in following physician orders and documenting care contributed to the deficiency identified by the surveyors.
Failure to Prevent Falls and Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for a resident with a history of falls and cognitive impairment. The resident, who was admitted with diagnoses including a history of traumatic fracture, Parkinson's Disease, and repeated falls, did not have a Fall Risk Assessment completed upon admission. Despite the facility's policy requiring such assessments within 24 hours of admission, this critical step was overlooked, leaving the resident without a tailored fall prevention plan. The resident experienced an unwitnessed fall resulting in significant injuries, including a laceration to the forehead and skin tears on both knees. The incident was not properly documented or investigated, as evidenced by the lack of a completed fall investigation report and missing documentation of neurologic checks after the resident returned from the hospital. The facility's Director of Nursing (DON) was unable to provide a comprehensive investigation or corrective actions, and there was no evidence of a fall log or follow-up as per the facility's policy. Interviews with staff revealed that the resident was often confused and attempted to ambulate without assistance, yet there was no effective intervention in place to address these behaviors. The resident's care plan was not updated in a timely manner, and the facility failed to report the fall with injury to the state, as required for such incidents. The lack of documentation and follow-up highlights a significant deficiency in the facility's fall prevention and response protocols.
Deficient Catheter Care and Infection Control Practices
Penalty
Summary
The facility failed to provide appropriate catheter care for Resident #96, who was observed with a urinary drainage bag hanging on the side of the bed without an anchoring device to secure the indwelling catheter. The resident, who has a history of neurogenic bladder and other medical conditions, was found to have an unsecured catheter, which was not in compliance with the facility's policy for catheter care. The resident had previously experienced a urinary tract infection, highlighting the importance of proper catheter management. During an observation of catheter care provided by Staff K, a CNA, several deficiencies were noted. The CNA did not perform hand hygiene after removing gloves and before putting on a new pair, which is against the facility's hand hygiene policy. Additionally, the CNA failed to provide privacy for the resident during the procedure, as the privacy curtain was not pulled, and the window blinds were not closed. The CNA also did not wear a gown, which is required under the facility's enhanced barrier precautions policy for high-contact resident care activities. The CNA's technique for cleaning the catheter was incorrect, as she wiped the catheter tubing from the drainage bag toward the resident's penis, rather than from the least contaminated to the most contaminated area. Furthermore, the catheter tubing was placed under the resident's leg without an anchor, which is not in accordance with the care plan's intervention to secure the catheter with a securement device. The Director of Nursing acknowledged these deficiencies during a side-by-side observation, confirming the improper placement and lack of anchoring for the Foley catheter.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to address significant weight loss in a timely manner for two residents, leading to deficiencies in nutritional care. Resident #14 experienced a 7.10% weight loss from January 7 to February 5, 2025, which was not addressed until February 13, 2025, when a nutritional note recommended adding Ensure and enhanced foods. However, documentation showed that the Ensure supplement was only recorded as given and accepted on 10 days out of the period from February 13 to March 8, 2025, without any percentage intake documented. Interviews with staff revealed that the documentation system only allowed for a yes or no response, and there was no option to record the percentage of supplement consumed. Resident #69 also experienced a significant weight loss of 18% from October 5 to December 5, 2024. A follow-up nutrition note on December 9, 2024, indicated a 17.2% weight loss trend, and Ensure was added twice a day for oral support. Despite this intervention, documentation from February 13 to March 8, 2025, showed that the Ensure supplement was only recorded as given and accepted on 23 out of 30 days, again without any percentage intake documented. Observations noted that Resident #69 was missing items from his breakfast tray, which were later provided by staff. Interviews with the Registered Dietitian and CNAs highlighted issues with the documentation process, as the system did not allow for detailed recording of supplement intake. The Registered Dietitian acknowledged that the response to significant weight loss should have been more prompt, and the CNAs confirmed that they could only document whether the supplement was taken, not the amount consumed. The facility's failure to adequately monitor and document nutritional intake contributed to the deficiencies identified by the surveyors.
Failure to Ensure Timely Physician Visits for a Resident
Penalty
Summary
The facility failed to ensure that the attending physician visits were performed in a timely manner for a resident with severe cognitive impairment. According to the facility's policy, residents should be seen by their physician at least monthly for the first 90 days following admission and at least once every 60 days thereafter. However, a review of the medical records for the resident revealed that there was no documentation from the attending physician, Staff H, indicating that he had performed a visit from December 6, 2024, to March 9, 2025. During an interview, Staff H stated that he sees residents initially every 30 days for the first 90 days and then alternates with the Nurse Practitioner (NP) every 60 days. He mentioned that the NP authors all notes and documents their collaboration on the plan of care, but he does not author any notes himself. The Director of Nursing acknowledged the lack of documentation indicating that the resident had been seen by the attending physician, confirming the deficiency in adhering to the facility's policy on physician visits.
Staffing Deficiency in Nursing and CNA Hours
Penalty
Summary
The facility failed to provide the minimum required nursing staff daily for 3 out of 28 days reviewed. According to the facility's policy, the minimum daily average hours for nursing staff should be 1.0 or greater, and for Certified Nursing Assistants (CNAs), it should be 2.0 or greater. However, the facility's Nurse Staffing Calculations from February 9, 2025, to March 8, 2025, showed that on February 15, 2025, the CNA daily average was 1.99, and on March 1, 2025, it was 1.97. Additionally, the nursing daily average was 0.98 hours on March 1, 2025, and 0.93 hours on March 8, 2025, both below the required minimum. Interviews with the Staffing Coordinator and the Director of Nursing confirmed that the staffing levels were below the required minimum during this period, particularly on weekends.
Incomplete Nurse Staffing Information Posting
Penalty
Summary
The facility failed to post complete and timely nurse staffing information for four consecutive days, as required by federal and state guidelines. Observations on multiple days revealed that the CMS Staff Postings at the nursing stations on both Unit 1 and Unit 2 only listed hours worked, without specifying the number of nursing staff or the name of the facility. This incomplete information was consistently observed on postings dated 02/28/25, 03/09/25, 03/11/25, and 03/12/25. Interviews with facility staff revealed a lack of clarity and consistency in the posting process. The Human Resources Director, who temporarily took over the posting duties, was unaware of the specific requirements and timing for posting the information. The regular Staffing Coordinator, who usually handles the postings, stated that she does not include the number of staff members on the postings, as this information is available on the assignment board at each nursing station. This practice led to the omission of required details on the CMS Staff Postings, contributing to the deficiency.
Non-compliance with PRN Psychotropic Medication Duration
Penalty
Summary
The facility failed to ensure that residents receiving PRN psychotropic medications were limited to 14 days or had documented rationale for extending the order beyond 14 days. This deficiency was identified for three residents. Resident #11 was admitted with anxiety and depression and was prescribed Alprazolam for 30 days without documentation justifying the extension beyond 14 days. Interviews with the Consultant Pharmacist and the Director of Nursing confirmed the lack of compliance with the 14-day limit. Resident #35, diagnosed with Generalized Anxiety Disorder, had a PRN order for Lorazepam without any documented rationale for extending the order beyond 14 days. The Director of Nursing acknowledged the absence of documentation to justify the extended use of the medication. The care plan for Resident #35 included interventions for mood changes but did not address the extended use of Lorazepam. Resident #15, with diagnoses of Generalized Anxiety Disorder and Major Depressive Disorder, had a PRN order for Alprazolam for 30 days. The Medication Administration Records for January, February, and March 2025 showed frequent administration of the medication, but there was no documentation of when the medication started or an end date. The Consultant Pharmacist and the Director of Nursing confirmed the lack of rationale for extending the PRN order beyond 14 days, indicating non-compliance with the facility's policy.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 13.33%. This deficiency was identified during medication administration observations involving two residents. Resident #85, who has Parkinson's Disease and moderate cognitive impairment, was administered medications significantly later than the prescribed time. The medications, including Carbidopa-Levodopa, Gabapentin, and Midodrine, were scheduled for 9:00 AM but were given at 12:00 PM. Additionally, the medications were improperly crushed and mixed with juice, contrary to administration guidelines. Interviews with staff revealed a lack of understanding regarding which medications should not be crushed, contributing to the error. Resident #11, diagnosed with Type 2 Diabetes Mellitus and moderate cognitive impairment, also experienced a medication administration error. The resident's Metformin was scheduled for 9:00 AM but was administered 1 hour and 50 minutes late. Interviews with staff indicated a misunderstanding of the facility's policy, which allows for a one-hour window before and after the scheduled time for medication administration. These errors highlight a failure in adhering to the facility's medication administration policies and procedures.
Medication Storage and Supervision Deficiencies
Penalty
Summary
The facility failed to ensure proper supervision and storage of medications for two residents, as well as secure medication carts. Resident #16, who has severe cognitive impairment and multiple diagnoses including dementia and depression, was observed with over-the-counter (OTC) medications such as Voltaren gel, saline nasal gel, and Refresh Tear eye drops left unattended on her bedside table and in her nightstand drawer. There was no physician order or care plan for self-administration of these medications, and staff confirmed that these items should not have been in the resident's room. Resident #307, who has no cognitive impairment but requires assistance with activities of daily living, was found with a tube of Voltaren gel on her bed. The resident stated she applied the gel before therapy, and the nurse was aware, but there was no physician order or care plan for self-administration. Staff removed the medications upon discovery and acknowledged the lack of proper authorization for the resident to have these medications at her bedside. Additionally, the facility failed to secure medication and treatment carts. An unlocked and unattended treatment cart was observed at the nursing station, and staff admitted it had not been used yet that day. Similarly, a medication cart was left unlocked and unattended by a nurse who had just arrived at the facility. A wound care cart containing prescription medications was also found unlocked and unattended, with the responsible nurse acknowledging she left it that way in a hurry.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety during multiple visits to the main kitchen. During the initial tour, several issues were identified, including a garbage bin with food debris and no lid in the food production area, and multiple sanitation buckets with no detectable sanitizing solution. Additionally, a square container with unidentified food and a jar of expired milk were found in the reach-in refrigerator, which was operating at an unsafe temperature of 58 degrees Fahrenheit. The walk-in refrigerator contained undated containers of Salisbury Steak and sandwiches past their use-by dates. The dishwasher machine was not functioning properly, with the wash cycle temperature below the required minimum. Personal water bottles were found in the food production area, and a cooking pot was noted with a dark sticky material. Egg salad plates were stored at unsafe temperatures, and the dietary aide confirmed they were prepared earlier that day. During a second visit, further deficiencies were observed, including an opened and unlabeled plastic bag of unidentified food in the walk-in freezer. These observations indicate a pattern of non-compliance with food safety standards, including improper food storage, inadequate sanitation practices, and equipment maintenance issues. The facility's failure to maintain proper food safety protocols poses a risk to the health and safety of its residents.
Inaccurate Documentation of Wound Care and Practitioner Roles
Penalty
Summary
The facility failed to maintain accurate clinical records for two residents, leading to deficiencies in care. For Resident #2, who was admitted with conditions including Parkinson's Disease and a history of falls, the facility did not accurately document wound care for a skin tear on the left knee. Despite physician orders for regular dressing changes, observations revealed that the dressing was not changed as documented in the Treatment Administration Record (TAR). The dressing was dated incorrectly, and there was no evidence that the resident refused treatment on several occasions, indicating a lack of accurate documentation and adherence to care protocols. For Resident #97, who was admitted with severe cognitive impairment and a history of traumatic subdural hemorrhage, the facility's records inaccurately listed a Nurse Practitioner as a Physician in the Medical Practitioner Notes. This misrepresentation occurred multiple times over several months, and there was no documentation of visits by the attending physician. The Director of Nursing acknowledged these inaccuracies, highlighting a failure in maintaining accurate and truthful medical records for the resident.
Infection Control Deficiencies in Equipment Disinfection and PPE Use
Penalty
Summary
The facility failed to adhere to CDC guidelines for Standard Precautions during the care of Resident #25. Staff Q, a Certified Nursing Assistant, was observed using the same set of gloves for multiple tasks, including opening the resident's door, handling trash, moving a meal table, and assisting with personal care, without changing gloves or performing hand hygiene. This action was contrary to the CDC's hand hygiene and PPE guidelines, which require changing gloves and washing hands between different tasks to prevent cross-contamination. In another instance, the facility did not properly disinfect vital signs equipment used for Residents #31 and #72. Staff O, a Registered Nurse, was observed using a blood pressure cuff and an oxygen saturation clip on Resident #31 without disinfecting them after prior use on Resident #72. Additionally, the equipment was returned to the storage basket without being cleaned, and there was no disinfectant available on the rolling vital signs machine. This failure to disinfect equipment between uses is a breach of CDC guidelines for the safe handling of potentially contaminated equipment. Resident #31, who had multiple health issues including Acute Respiratory Failure and a Multi Drug Resistant Klebsiella Urinary Tract Infection, was at risk due to the lack of proper equipment disinfection. Similarly, Resident #72, who was waiting for medication and had not yet had their blood pressure taken, was exposed to potential infection risks due to the improper handling of the blood pressure cuff. These observations highlight the facility's failure to maintain proper infection control practices, as confirmed by Staff R, an RN, who stated that staff were trained to perform hand hygiene and disinfect equipment, but these practices were not consistently followed.
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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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