Citations in Florida
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Florida.
Statistics for Florida (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Florida
Surveyors identified that the facility did not maintain required documentation for 1.5-hour load bank testing, monthly generator load testing, weekly voltage checks, or monthly conductance testing for generator batteries. These omissions were confirmed during a record review and acknowledged by facility leadership.
Surveyors identified that the facility's Emergency Preparedness Program lacked required contact information for all staff and residents' physicians in its communication plan. The Administrator acknowledged these omissions during the review, and the findings were discussed with facility leadership.
Surveyors found that the facility's Emergency Preparedness Program listed satellite phones as an alternate means of communication, but the facility was unable to produce a satellite phone for inspection when requested. The Administrator confirmed that the alternate communication device was not available as required.
Surveyors found that two delayed egress exit doors lacked the required signage with a contrasting background, and one door in the Service Hallway automatically reset when tested, both in violation of NFPA 101 standards. These deficiencies were observed during a fire safety tour and acknowledged by facility leadership.
The facility did not complete required sensitivity testing for all smoke and duct detectors as mandated by NFPA 101 and NFPA 72. Record review revealed that 11 smoke detectors and two duct detectors were not tested, and inspection reports lacked documentation of sensitivity testing results. The Regional Maintenance Director acknowledged these findings during the survey.
Surveyors found that the Main Lobby had mixed sprinkler coverage, with two quick response and two standard sprinklers, which does not comply with NFPA requirements. The Regional Maintenance Director acknowledged the issue during the inspection, and the deficiency was documented with photographic evidence.
Surveyors found that a medication refrigerator was not connected to a distinctly marked receptacle powered by the critical branch of the EES, as required by NFPA 99. Additionally, the facility failed to provide documentation for required maintenance and testing of the EES, including generator inspections and load exercises. These deficiencies were confirmed through observation, staff interviews, and record review, affecting all residents receiving refrigerated medications and those dependent on emergency power systems.
A resident with significant self-care limitations due to recent surgery and left-sided impairment reported long delays in call-light response and dissatisfaction with ADL care. Despite communicating these concerns to staff and family members reporting issues to the Administrator, no grievance documentation was found, and the facility failed to demonstrate a response to the resident's complaints as required by regulation.
A resident was found to have a vascular access device in place for eleven days without any physician orders for its care, maintenance, or removal. Nursing staff did not document or communicate the presence of the device, and no orders were obtained until prompted by surveyors. The device remained unused, and the resident was unaware of its purpose during their stay.
A resident had a line in place in the left upper arm for eleven days without a physician's order for its removal or care, and staff failed to notify the DON or physician or document the line in the care plan or progress notes. The line remained in place and unused, with visible discoloration at the site, and an order for removal was only obtained after surveyor inquiry.
Failure to Maintain and Document Essential Electrical System Testing
Penalty
Summary
The facility failed to maintain the Essential Electrical System (EES) in accordance with NFPA 99 requirements, as evidenced by missing documentation and incomplete testing records. During a record review with the Regional Director of Plant Operations, surveyors found that there was no documentation for the required 1.5-hour load bank testing for 2024, nor was there evidence of monthly testing under a thirty percent load. This testing is necessary to ensure the generator can supply emergency power as required by regulation. Additionally, the facility did not provide documentation of weekly voltage checks for the two generator batteries. Regular monitoring of battery voltage is essential to confirm that the generator will function properly in the event of a power outage. The absence of these records indicates that the facility did not consistently monitor the generator batteries as required. Furthermore, there was no documentation of monthly conductance testing for the generator's two sealed batteries prior to 2025. Conductance testing is a standard procedure to assess the health and reliability of the batteries that support the emergency power system. The Regional Maintenance Director acknowledged these findings during the survey, and the deficiencies were reviewed with both the Administrator and the Regional Maintenance Director at the exit conference.
Plan Of Correction
Corrective Action for Affected Residents: The facility will correct deficiencies related to generator maintenance and testing documentation to ensure the Essential Electrical System (EES) is maintained in accordance with NFPA requirements. Specifically: weekly generator inspection forms provided by TELs will be updated to include battery voltage readings for both generator batteries. Monthly generator testing forms will be updated to include battery conductance testing for sealed batteries. Monthly generator load testing documentation will reflect testing at a minimum of thirty percent (30%) of nameplate capacity, and a four (4) hour continuous load bank test was completed in and will be conducted annually, with the next and annually thereafter. These actions will ensure reliable emergency power is available to protect residents, staff, and essential services. Identification of Other Residents Potentially Affected: The facility will conduct a review of all generator maintenance and testing records to ensure compliance with NFPA 110 requirements, including weekly inspections, monthly testing, battery monitoring, and extended load testing. Measures to Prevent Recurrence: Generator inspection and testing forms provided by TELs will be permanently revised to include required weekly battery voltage readings and monthly battery conductance testing. The four (4) hour load bank test will be scheduled annually, with the next test due and annually thereafter. The Maintenance Director will be educated on NFPA 99 and NFPA 110 requirements related to generator testing, battery monitoring, and documentation. Monitoring/Quality Assurance: Generator logs will be reviewed monthly by leadership and monitored through the QAPI program. An unannounced Fire & Life Safety Recertification survey was conducted on at Nspire Healthcare Tamarac, a nursing home in Tamarac, Florida. Nspire Healthcare Tamarac is not in compliance with 42 CFR 483 Subpart B, 42 CFR 488.307, and National Fire Protection Association (NFPA) 101 (2012 Edition), NFPA 99 (2012 Edition) requirements for nursing homes. Initial Plan Review. 1994 Existing NFPA 220 Construction Type: II (111) Number of beds: 151 Census: 122 The following is a description of the noncompliance. Corrective Action for Affected Residents: The facility will correct deficiencies related to generator maintenance and testing documentation to ensure the Essential Electrical System (EES) is maintained in accordance with NFPA requirements. Specifically: weekly generator inspection forms provided by TELs will be updated to include battery voltage readings for both generator batteries. Monthly generator testing forms will be updated to include battery conductance testing for sealed batteries. Monthly generator load testing documentation will reflect testing at a minimum of thirty percent (30%) of nameplate capacity, and a four (4) hour continuous load bank test was completed in and will be conducted annually, with the next and annually thereafter. These actions will ensure reliable emergency power is available to protect residents, staff, and essential services. Identification of Other Residents Potentially Affected: The facility will conduct a review of all generator maintenance and testing records to ensure compliance with NFPA 110 requirements, including weekly inspections, monthly testing, battery monitoring, and extended load testing. Measures to Prevent Recurrence: Generator inspection and testing forms provided by TELs will be permanently revised to include required weekly battery voltage readings and monthly battery conductance testing. The four (4) hour load bank test will be scheduled annually, with the next test due and annually thereafter. The Maintenance Director will be educated on NFPA 99 and NFPA 110 requirements related to generator testing, battery monitoring, and documentation. Monitoring/Quality Assurance: Generator logs will be reviewed monthly by leadership and monitored through the QAPI program. [Repeated sections with placeholders such as [R] and incomplete dates are included as in the original text.]
Incomplete Emergency Preparedness Communication Plan
Penalty
Summary
During a review of the facility's Emergency Preparedness Program (EP), surveyors found that the facility did not maintain a complete communication plan as required by federal regulations. Specifically, the communication plan was missing contact information for all staff members and for residents' physicians. This omission was identified during a record review conducted with the facility Administrator. The deficiency was confirmed through both documentation review and an interview with the Administrator, who acknowledged the absence of the required contact information in the EP. The findings were also discussed with the Regional Maintenance Director during the exit conference. No information was provided in the report regarding specific residents or their medical conditions at the time of the deficiency. The focus of the deficiency was solely on the incomplete communication plan within the facility's emergency preparedness documentation.
Plan Of Correction
Corrective Action for Affected Residents: The Administrator added a phone list of all employees and primary physicians that attend the facility. Identification of Other Residents Potentially Affected: This deficient practice did not affect any residents. Measures to Prevent Recurrence: Administrator was educated by the Regional Maintenance Director on reviewing annually the Emergency Preparedness Manual to ensure all contacts are current. Monitoring / Quality Assurance: Emergency Preparedness Manual will be reviewed annually and findings submitted to QAPI. E0030 Corrective Action for Affected Residents: The Administrator added a phone list of all employees and primary physicians that attend the facility. Identification of Other Residents Potentially Affected: This deficient practice did not affect any residents. Measures to Prevent Recurrence: Administrator was educated by the Regional Maintenance Director on reviewing annually the Emergency Preparedness Manual to ensure all contacts are current. Monitoring / Quality Assurance: Emergency Preparedness Manual will be reviewed annually and findings submitted to QAPI. E0030
Failure to Provide Alternate Communication Device Listed in Emergency Plan
Penalty
Summary
During a Fire & Life Safety re-licensure survey, surveyors reviewed the facility's Emergency Preparedness Program (EP) and found that the facility had listed satellite phones as an alternate means of communication in their emergency plan. However, when requested, the facility was unable to produce a satellite phone for inspection. This deficiency was identified through both record review and staff interview, where the absence of the listed communication device was confirmed. The Administrator acknowledged the findings during the interview and at the exit conference, confirming that the alternate communication method described in the EP was not available as required by federal regulations. The deficiency specifically relates to the facility's failure to ensure that the alternate means of communication, as outlined in their emergency preparedness plan, was present and accessible for inspection.
Plan Of Correction
Corrective Action for Affected Residents: The administrator added an updated list of primary and alternate means of communication. The facility does not use satellite phones. Identification of Other Residents Potentially Affected: This deficient practice did not affect any residents. Measures to Prevent Recurrence: The administrator was educated by the Regional Maintenance Director on reviewing annually the Emergency Preparedness Manual to ensure primary and alternate means of communication for the facility are listed. Monitoring/Quality Assurance: The Emergency Preparedness Manual will be reviewed annually, and findings will be submitted to QAPI.
Deficient Delayed Egress Door Signage and Function
Penalty
Summary
Surveyors observed that the facility failed to maintain egress doors equipped with delayed egress locking arrangements in accordance with NFPA 101 requirements. During a fire safety tour, it was found that two delayed egress exit doors—the first floor West Wing Rehabilitation Room door and the Service Hallway door—did not have the required signage with a contrasting background. This signage is necessary to comply with fire safety codes and to ensure that the doors are easily identifiable in an emergency. Additionally, the Service Hallway delayed egress exit door exhibited a malfunction during testing. Specifically, the door automatically reset when it was tested, which is not in accordance with the required operation for delayed egress doors. This issue could potentially interfere with the proper function of the delayed egress system, which is designed to allow safe evacuation during emergencies. The findings were confirmed through direct observation by surveyors and acknowledged by the Regional Maintenance Director during the inspection. The deficiency was reviewed with both the Administrator and the Regional Maintenance Director at the exit conference. Photographic evidence was obtained to document the observed issues. No information was provided regarding specific residents affected or their medical conditions at the time of the deficiency.
Plan Of Correction
Corrective Action for Affected Residents: The facility will correct the delayed-egress door deficiencies to ensure proper operation and compliance with NFPA 101. Specifically: The first floor West Wing Rehabilitation Room delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be repaired right away to ensure the door does not automatically reset and operates in accordance with delayed-egress requirements. Identification of Other Residents Potentially Affected: The facility will conduct a facility-wide inspection of all delayed-egress doors to verify: Required signage is present and has a contrasting background and delayed-egress doors function properly and do not automatically reset. Any additional deficiencies identified will be corrected. Measures to Prevent Recurrence: Delayed-egress doors will be routinely inspected to confirm required signage is present and door operation complies with NFPA 101. Maintenance leadership will be educated on NFPA 101 requirements related to delayed-egress door signage and functionality. Monitoring/Quality Assurance: Delayed-egress door inspections will be documented and reviewed during routine maintenance rounds. Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified. Corrective Action for Affected Residents: The facility will correct the delayed-egress door deficiencies to ensure proper operation and compliance with NFPA 101. Specifically: The first floor West Wing Rehabilitation Room delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be repaired right away to ensure the door does not automatically reset and operates in accordance with delayed-egress requirements. Identification of Other Residents Potentially Affected: The facility will conduct a facility-wide inspection of all delayed-egress doors to verify: Required signage is present and has a contrasting background and delayed-egress doors function properly and do not automatically reset. Any additional deficiencies identified will be corrected. Measures to Prevent Recurrence: Delayed-egress doors will be routinely inspected to confirm required signage is present and door operation complies with NFPA 101. Maintenance leadership will be educated on NFPA 101 requirements related to delayed-egress door signage and functionality. Monitoring/Quality Assurance: Delayed-egress door inspections will be documented and reviewed during routine maintenance rounds. Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified. Corrective Action for Affected Residents: The facility will correct the delayed-egress door deficiencies to ensure proper operation and compliance with NFPA 101. Specifically: The first floor West Wing Rehabilitation Room delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be provided with the required delayed-egress signage with a contrasting background. The Service Hallway delayed-egress exit door will be repaired right away to ensure the door does not automatically reset and operates in accordance with delayed-egress requirements. Identification of Other Residents Potentially Affected: The facility will conduct a facility-wide inspection of all delayed-egress doors to verify: Required signage is present and has a contrasting background and delayed-egress doors function properly and do not automatically reset. Any additional deficiencies identified will be corrected. Measures to Prevent Recurrence: Delayed-egress doors will be routinely inspected to confirm required signage is present and door operation complies with NFPA 101. Maintenance leadership will be educated on NFPA 101 requirements related to delayed-egress door signage and functionality. Monitoring/Quality Assurance: Delayed-egress door inspections will be documented and reviewed during routine maintenance rounds. Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified.
Failure to Complete Required Fire Alarm System Sensitivity Testing
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with NFPA 101 and NFPA 72 standards. During a record review with the Regional Maintenance Director, it was found that the biennial smoke detector sensitivity testing did not include 11 out of 73 smoke detectors. Additionally, the repairs inspection report did not indicate that the smoke detectors were sensitivity tested, nor did it provide the results of such testing. The annual fire alarm report listed 23 duct detectors in the inventory, but the duct detector differential pressure testing documented 24 duct detectors tested, and the smoke detector sensitivity testing only included 22 duct detectors, leaving two duct detectors untested for sensitivity. These discrepancies were identified through a combination of record review and staff interviews. The Regional Maintenance Director acknowledged the findings during the review. The records failed to demonstrate that all required smoke and duct detectors underwent the necessary sensitivity testing as mandated by the applicable codes and standards. The deficiency affects all residents and staff in the affected smoke compartments, as the fire alarm system is a critical component of the facility's safety infrastructure. The findings were reviewed with both the Administrator and the Regional Maintenance Director at the exit conference, and photographic evidence was obtained to support the observations.
Plan Of Correction
Corrective Action for Affected Residents: All smoke detectors and duct detectors identified as not sensitivity tested or inconsistently documented will be addressed/tested. The facility will be coordinating with the licensed fire alarm vendor to: complete sensitivity testing on the 11 of 73 smoke detectors that were not tested during the biennial testing dated. Complete sensitivity testing on the two (2) duct detectors that were not included in prior sensitivity testing. Reconcile and correct discrepancies between: smoke detector sensitivity testing reports, duct detector differential pressure testing reports, and annual fire alarm inspection reports. Identification of Other Residents Potentially Affected: A 100% review of fire alarm testing records was conducted to ensure all devices are included and properly documented. Measures to Prevent Recurrence: Maintenance leadership will be re-educated on NFPA 72 sensitivity testing requirements and the importance of reconciling all fire alarm testing reports for consistency and completeness prior to acceptance. Monitoring / Quality Assurance: Annual testing will be verified by the Maintenance Director and reviewed by the Administrator during Life Safety reviews. Corrective Action for Affected Residents: The facility will correct the identified sprinkler system deficiency to ensure consistent and reliable fire protection within the affected smoke compartment. Specifically, the two (2) sprinkler heads in the Main Lobby that were identified as standard response sprinklers were scheduled for replacement. These sprinkler heads will be replaced with quick response sprinkler heads to ensure uniform sprinkler response characteristics throughout the area. Replacement will be completed by a licensed fire sprinkler contractor, and documentation will be maintained on-site. Identification of Other Residents Potentially Affected: To identify any additional areas that may be affected. Corrective Action for Affected Residents: All smoke detectors and duct detectors identified as not sensitivity tested or inconsistently documented will be addressed/tested. The facility will be coordinating with the licensed fire alarm vendor to: complete sensitivity testing on the 11 of 73 smoke detectors that were not tested during the biennial testing dated. Complete sensitivity testing on the two (2) duct detectors that were not included in prior sensitivity testing. Reconcile and correct discrepancies between: smoke detector sensitivity testing reports, duct detector differential pressure testing reports, and annual fire alarm inspection reports. Identification of Other Residents Potentially Affected: A 100% review of fire alarm testing records was conducted to ensure all devices are included and properly documented. Measures to Prevent Recurrence: Maintenance leadership will be re-educated on NFPA 72 sensitivity testing requirements and the importance of reconciling all fire alarm testing reports for consistency and completeness prior to acceptance. Monitoring / Quality Assurance: Annual testing will be verified by the Maintenance Director and reviewed by the Administrator during Life Safety reviews.
Deficiency in Sprinkler System Compliance
Penalty
Summary
The facility failed to maintain its automatic fire sprinkler system (AFSS) in accordance with NFPA 101 and related standards for one of twelve sampled smoke compartments. During a fire safety tour, surveyors observed that the Main Lobby contained mixed sprinkler coverage, with two of the four sprinklers being quick response and the other two being standard sprinklers. This observation was made in the presence of the Regional Maintenance Director, who acknowledged the findings at the time. The deficiency was identified through a combination of direct observation, record review, and staff interviews. The surveyors specifically noted the inconsistency in the type of sprinkler heads installed within the same area, which does not comply with the requirements set forth by NFPA 13 and NFPA 25. The issue was discussed with both the Administrator and the Regional Maintenance Director during the exit conference, and photographic evidence was obtained to document the condition. No information was provided in the report regarding any residents' medical history or their condition at the time of the deficiency. The deficiency was limited to the fire protection system in the Main Lobby smoke compartment, and the report did not mention any immediate consequences or incidents resulting from the mixed sprinkler coverage. The focus of the findings was on the facility's failure to ensure uniform and compliant sprinkler system installation and maintenance as required by applicable fire safety codes.
Plan Of Correction
Continued from page 4 By the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI. Corrective Action for Affected Residents: The facility will correct the identified sprinkler system deficiency to ensure consistent and reliable fire protection within the affected smoke compartment. Specifically: The two (2) sprinkler heads in the Main Lobby that were identified as standard response sprinklers were scheduled for replacement. These sprinkler heads will be replaced with quick response sprinkler heads to ensure uniform sprinkler response characteristics throughout the area. Replacement will be completed by a licensed fire sprinkler contractor, and documentation will be maintained on-site. Identification of Other Residents Potentially Affected: To identify any additional areas that may be affected by the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI. Will correct the identified sprinkler system deficiency to ensure consistent and reliable fire protection within the affected smoke compartment. Specifically: The two (2) sprinkler heads in the Main Lobby that were identified as standard response sprinklers were scheduled for replacement. These sprinkler heads will be replaced with quick response sprinkler heads to ensure uniform sprinkler response characteristics throughout the area. Replacement will be completed by a licensed fire sprinkler contractor, and documentation will be maintained on-site. Identification of Other Residents Potentially Affected: To identify any additional areas that may be affected by the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI. By the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI. Will correct the identified sprinkler system deficiency to ensure consistent and reliable fire protection within the affected smoke compartment. Specifically: The two (2) sprinkler heads in the Main Lobby that were identified as standard response sprinklers were scheduled for replacement. These sprinkler heads will be replaced with quick response sprinkler heads to ensure uniform sprinkler response characteristics throughout the area. Replacement will be completed by a licensed fire sprinkler contractor, and documentation will be maintained on-site. Identification of Other Residents Potentially Affected: To identify any additional areas that may be affected by the same deficient practice: A facility-wide inspection of sprinkler heads was conducted by maintenance leadership to verify sprinkler type, response classification (quick response vs. standard response), and consistency within smoke compartments and common areas. Any future discrepancies identified will be corrected immediately. Measures to Prevent Recurrence: All future sprinkler repairs or replacements will require verification that sprinkler heads match the existing sprinkler type in the area. The Maintenance Director will review and approve all sprinkler work to ensure system consistency. The Maintenance Director was educated on applicable NFPA requirements related to sprinkler system consistency and sprinkler response type. Monitoring / Quality Assurance: Inspection and testing records will be maintained and reviewed annually through QAPI.
Medication Refrigerator Not Connected to Critical Branch and EES Maintenance Documentation Lacking
Penalty
Summary
The facility failed to ensure that electrical receptacles serving medication preparation areas, specifically those used for medication refrigerators, were connected to the critical branch of the Essential Electrical System (EES) and were not distinctly marked as required by NFPA 99. During a fire safety tour, it was observed that a medication refrigerator was not plugged into a receptacle powered by the critical branch, and the required distinctive color or marking was absent. This deficiency was acknowledged by the Regional Maintenance Director during the observation and was reviewed with facility leadership at the exit conference. Photographic evidence was obtained to document the finding. Additionally, the facility did not maintain proper documentation for the maintenance and testing of the EES, including the generator and associated equipment. Required records for weekly inspections, monthly load exercises, and other scheduled maintenance activities were not provided during the record review with the Regional Director of Plant Operations. The lack of documentation means that the facility could not demonstrate compliance with NFPA 99, NFPA 110, and related standards for ensuring the reliability of emergency power systems. These deficiencies affect all residents who receive refrigerated medications from the affected medication room, as well as all residents and staff who rely on the facility's emergency electrical systems. The findings were based on direct observation, staff interviews, and record reviews conducted by surveyors during the inspection.
Plan Of Correction
Corrective Action for Affected Residents: The room medication refrigerator will be correctly tied into critical branch breaker to ensure it is supplied by the critical branch of the essential electrical system along with a distinctly marked critical branch receptacle, ensuring uninterrupted power during normal and emergency conditions for residents receiving refrigerated medications. Identification of Other Residents Potentially Affected: The facility conducted a review of all medication refrigerators and receptacles supplied by the essential electrical system, including medication preparation areas, to verify proper connection to and identification of critical branch power. Measures to Prevent Recurrence: All medication refrigerators will be verified to be connected to and powered by the critical branch. The Maintenance Director was educated on NFPA 99 requirements related to essential electrical system branch identification and medication refrigeration power sources. Monitoring/Quality Assurance: Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified. Corrective Action for Affected Residents: The facility will correct deficiencies related to generator maintenance and testing documentation to ensure the Essential Electrical System (EES) is maintained in accordance with NFPA requirements. Specifically: Weekly generator inspection forms provided by TELs will be updated to include battery voltage readings for both generator batteries. Monthly generator testing forms will be updated to include battery conductance testing for sealed batteries. Monthly generator load testing documentation will reflect testing at a minimum of thirty percent (30%) of nameplate capacity, and a four (4) hour continuous load bank test was completed in [date] and will be conducted annually, with the next test due [date], and annually thereafter. These actions will ensure reliable emergency power is available to protect residents, staff, and essential services. Identification of Other Residents Potentially Affected: The facility will conduct a review of all generator maintenance and testing records to ensure compliance with NFPA 110 requirements, including weekly inspections, monthly testing, battery monitoring, and extended load testing. Measures to Prevent Recurrence: Generator inspection and testing forms provided by TELs will be permanently revised to include required weekly battery voltage readings and monthly battery conductance testing. The four (4) hour load bank test will be scheduled annually, with the next test due [date], and annually thereafter. The Maintenance Director will be educated on NFPA 99 and NFPA 110 requirements related to generator testing, battery monitoring, and documentation. Monitoring/Quality Assurance: Generator logs will be reviewed monthly by leadership and monitored through the QAPI program. Corrective Action for Affected Residents: The room medication refrigerator will be correctly tied into critical branch breaker to ensure it is supplied by the critical branch of the essential electrical system along with a distinctly marked critical branch receptacle, ensuring uninterrupted power during normal and emergency conditions for residents receiving refrigerated medications. Identification of Other Residents Potentially Affected: The facility conducted a review of all medication refrigerators and receptacles supplied by the essential electrical system, including medication preparation areas, to verify proper connection to and identification of critical branch power. Measures to Prevent Recurrence: All medication refrigerators will be verified to be connected to and powered by the critical branch. The Maintenance Director was educated on NFPA 99 requirements related to essential electrical system branch identification and medication refrigeration power sources. Monitoring/Quality Assurance: Compliance will be reviewed by the Administrator or designee through the facility's QAPI program, and corrective action will be taken immediately if deficiencies are identified.
Failure to Document and Respond to Resident Grievances Regarding Care Delays
Penalty
Summary
A deficiency was identified when the facility failed to provide evidence of documented grievances submitted by a resident regarding delays in call-light response and concerns related to activities of daily living (ADL) care. The resident, who was alert, oriented, and verbally responsive, had significant self-care limitations due to left-sided impairment and recent right-sided surgery. Her care plan required assistance with bathing, eating, hygiene, mobility, toileting, transfers, skin assessments, and the use of a call bell for help. Despite these needs, the resident reported waiting approximately four hours for assistance after activating her call light during nighttime hours and expressed dissatisfaction with the quality of care received upon admission. The resident stated that she communicated her concerns to nursing staff, but no improvements were observed. She also reported that certified nursing assistants (CNAs) told her they were responsible for 16 residents and did not have adequate time to provide timely care. The resident's family reported concerns to the Administrator but perceived the response as indifferent. Additionally, when the resident requested to receive ADL care before other residents due to her functional limitations, staff reportedly told her that permanent residents were prioritized over her. The administration did not address her complaints, and no documentation of her grievances was found. Interviews with staff revealed that while the resident's complaints were communicated to the Director of Nursing (DON) and documented in the facility's electronic system for other residents, no grievance documentation was submitted for this resident. The social worker confirmed that no grievance submissions were received from the resident and that there was no documentation indicating staff had submitted grievances on her behalf. The DON also stated that she had not received complaints from the resident or her family and described the facility's grievance procedure, which requires documentation and resolution within three days. However, no documentation existed for the resident's grievance, resulting in noncompliance with regulatory requirements.
Plan Of Correction
Resident #75 - grievances regarding ADL care and call light response were documented and addressed. A quality audit of current residents was conducted to ensure there are no undocumented grievances regarding delay in call light response and concerns related to activities of daily living (ADL) care. The Director of Nursing will educate the nursing staff on ensuring that grievances with residents' concerns are documented and addressed. The Director of Nursing and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure that staff is documenting grievances with residents' concerns. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly for 3 months or until substantial compliance has been met. per physician orders.
Failure to Obtain Physician Orders for Vascular Access Device Care and Removal
Penalty
Summary
A deficiency occurred when the facility failed to obtain physician orders for the care, maintenance, or removal of a vascular access device in a resident. Upon re-admission, the resident had a vascular access device in the left upper arm, which was observed to remain in place for eleven days without any documented physician orders for its care or discontinuance. The facility's policy required nurses to obtain and verify physician orders for such devices, including their removal, care, and maintenance, but this was not followed. Multiple observations confirmed the device remained in place, with visible brownish discoloration and a small, darkened area at the site. The resident reported not receiving any medication through the device since admission and was unaware of the reason for its continued presence. Review of the resident's medical records, including physician orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR), revealed no orders for the device's care, maintenance, or removal during the resident's stay. Interviews with nursing staff indicated a lack of awareness regarding the device's presence and the absence of any action to obtain necessary physician orders. The nurse who changed the dressing admitted to not notifying the oncoming nurse, the DON, or the physician about the device, stating she had forgotten to do so. There was no documentation in the nursing progress notes, baseline care plan, or comprehensive care plan regarding the device, and the physician was not contacted for orders until prompted by the surveyor.
Plan Of Correction
A quality audit of current residents was conducted to ensure that no ([R]) were noted without a physician order in place. The Director of Nursing educated licensed nurses on ensuring that a physician order is obtained for residents with ([R]) lines. The Director of Nursing and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure that a physician order is obtained for ([R]) residents with [R] lines. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.
Failure to Obtain Physician's Order and Document Care for Unused Line
Penalty
Summary
A resident had a line in place in the left upper arm for eleven days without a current physician's order for its discontinuance or for its care and maintenance. Multiple observations confirmed the line remained in place and was not in use, with the site showing brownish discoloration and a small, darkened area noted in the tubing. The physician's orders for the resident only included two oral medications, with no order for the line during the facility stay. Staff who identified the line did not notify the oncoming nurse, the DON, or the resident's physician to obtain appropriate orders for removal or care, stating she had forgotten to do so. There was no documentation in the nursing admission progress notes, ongoing nursing progress, baseline care plan, or comprehensive care plan regarding the identification or existence of the line. The physician's order to remove the line was only obtained after surveyor inquiry.
Some of the Latest Corrective Actions taken by Facilities in Florida
- Implemented comprehensive nurse education on verifying absence of vital signs, honoring DNR orders, provider notification by telephone, and accurate documentation (J - F0726 - FL) (J - F0600 - FL) (J - F0578 - FL)
- Delivered abuse-and-neglect training emphasizing adherence to residents’ code-status wishes (J - F0726 - FL) (J - F0600 - FL) (J - F0578 - FL)
- Established an orientation requirement ensuring all newly hired staff complete the above education before working (J - F0726 - FL) (J - F0600 - FL) (J - F0578 - FL)
- Mandated double-nurse confirmation of absent vital signs and prohibited nurses from pronouncing death, with required DON notification (J - F0726 - FL) (J - F0600 - FL) (J - F0578 - FL)
- Instituted ongoing QAPI committee oversight of advance-directive processes, code-status documentation, audits, and education compliance (J - F0726 - FL) (J - F0600 - FL) (J - F0578 - FL)
- Launched continuous audits of code-status binders and electronic records for all new or readmitted residents, with QAPI review of findings (J - F0726 - FL) (J - F0600 - FL) (J - F0578 - FL)
- Continued scheduled Code Blue drills until every nurse demonstrated competency (J - F0726 - FL) (J - F0600 - FL) (J - F0578 - FL)
- Distributed electronic education materials and required nurses to sign acknowledgment sheets prior to shift assignment (J - F0726 - FL) (J - F0600 - FL) (J - F0578 - FL)
Failure to Honor DNR Order Due to Staff Incompetency in Code Status Verification
Penalty
Summary
Nursing staff failed to verify and honor a resident's Do Not Resuscitate (DNR) order when the resident was found unresponsive and without a pulse. Despite the presence of a valid DNR order in the medical record and code status binders, a registered nurse initiated chest compressions before being informed of the resident's DNR status, at which point resuscitation efforts were discontinued. The incident occurred after the nurse instructed a CNA to call a code and began CPR, only stopping after being notified of the DNR order. The resident involved had multiple diagnoses, including dementia, Type 2 Diabetes Mellitus, vascular implants, osteoarthritis, chronic kidney disease, anxiety, depression, insomnia, hypertension, and Hodgkin's Lymphoma. The resident's care plan and medical record clearly indicated a DNR order, and the resident was severely cognitively impaired, as evidenced by a low BIMS score. Staff interviews revealed that the nurse involved had not received specific training on CPR or DNR procedures, nor on how to locate code status information in the facility's systems or binders during orientation. Further review of facility policies, job descriptions, and orientation materials showed that while procedures and competencies regarding code status and DNR orders existed, they were not effectively communicated or implemented with all staff. The nurse involved was unaware of the location of DNR documentation and the process for verifying code status, leading to the failure to honor the resident's advance directive at the time of the emergency. This deficiency resulted in the determination of Immediate Jeopardy.
Removal Plan
- Audit code status binders to validate DNR forms are in the appropriate binder.
- Audit to verify residents' DNR forms are present in the electronic medical record, physician orders are in place, and care plans are reflective of residents' code status.
- Provide staff education instructing licensed nurses to evaluate residents for absence of vital signs and to follow residents' Advanced Directive if vital signs are absent.
- If the resident has DNR orders, staff are to notify the provider for further orders.
- Provide staff education on Abuse and Neglect, with emphasis on the importance of following residents' wishes regarding code status.
- Initiate a process for newly hired facility staff to receive the above education during orientation and prior to working any assignment.
- Conduct QAPI committee meetings to review adherence to policy and procedure for advance directives, code status in the electronic health record, code status binders, following physician orders, and results of the root cause analysis.
- QAPI committee to review the plan viability of the advance directives process, code process, code status binder process, and audit results.
- QAPI committee to review ongoing monitoring audits including education validation; ensure staff interviewed answer questions appropriately.
- Continue Code Blue drills until all nursing staff participate.
- QAPI committee to review ongoing audits, including validation of code status for new/re-admissions and staff education during general orientation.
- QAPI committee to continue review of ongoing monitoring audits including education validation, code status validation for new/re-admissions, and orientation education.
- Provide licensed nurses additional education on two nurses confirming the absence of vital signs and notifying the health care provider by telephone, not text, for orders and to clearly document in the medical record.
- Director of Nursing and Unit Manager designees to educate licensed nurses on evaluating residents for the absence of vital signs and following the residents' Advanced Directive.
- For residents with DNR orders or if death occurs in the facility, notify the physician for further orders.
- Require staff to notify the DON when a resident is noted to be absent of vital signs.
- Emphasize in education that, per the Nurse Practice Act, only a physician may pronounce death; a licensed nurse (RN or LPN) cannot do so.
- Distribute an electronic copy of the education to all nurses.
- Require licensed nurses to sign the education acknowledgment sheet before working.
- Conduct interviews with CNAs and licensed nurses to verify education related to their role during a Code Blue, the Stop, Think, and Perform process, resident rights, participation in Code Blue drills, and education on resident rights.
- Review in-service attendance signature sheets and a log of electronic communications to confirm training completion.
Failure to Honor DNR Order and Verify Code Status
Penalty
Summary
A deficiency occurred when staff failed to honor a resident's Do Not Resuscitate (DNR) order during a medical emergency. The resident, who had severe cognitive impairment and multiple medical diagnoses including dementia, diabetes, and chronic kidney disease, was found unresponsive and without a pulse. Despite the presence of a valid DNR order in both the medical record and the facility's designated binder, a registered nurse initiated chest compressions before being informed of the resident's DNR status and subsequently discontinued resuscitation efforts. Interviews revealed that the nurse involved had not received adequate training on CPR or DNR procedures, nor on how to locate a resident's code status in the electronic health record or the physical binder. Other staff members, including CNAs and LPNs, were unclear about their roles during a code situation and the process for verifying code status. The facility's policy required two nurses to verify code status before initiating CPR, but this protocol was not followed in this incident. Documentation confirmed that the resident's care plan and medical orders clearly indicated a DNR status, and the facility's policies emphasized the right of residents to refuse treatment and have their advance directives honored. However, the failure to verify and adhere to the resident's DNR order resulted in the initiation of unwanted resuscitative measures, constituting neglect as defined by the facility's own policies and federal regulations.
Removal Plan
- Audit of the code status binders to validate DNR forms are in the appropriate binder.
- Audit to verify residents' DNR forms are present in the electronic medical record, physician orders are in place, and care plans are reflective of residents' code status.
- Staff education provided instructing licensed nurses to evaluate residents for absence of vital signs, and if vital signs are absent, to follow residents' Advanced Directive. If the resident has DNR orders, notify the provider for further orders.
- Staff received education on Abuse and Neglect, with emphasis on the importance of following residents' wishes regarding code status.
- Process initiated for newly hired facility staff to receive the above education during orientation and prior to working any assignment.
- Ad hoc Quality Assurance and Performance Improvement (QAPI) committee meeting conducted with the Medical Director, Administrator, Director of Nursing, and additional IDT members to review adherence to policy and procedure for advance directives, code status in the electronic health record, code status binders, following physician orders, and results of the root cause analysis.
- QAPI committee reviewed the plan viability of the advance directives process, code process, code status binder process, and audit results.
- QAPI committee reviewed education completion rates.
- QAPI committee discussed ongoing monitoring audits including education validation.
- Code Blue drills continue until nursing staff participate.
- QAPI committee reviewed ongoing audits, including validation of code status for new/re-admissions and staff education during general orientation.
- QAPI committee continued review of ongoing monitoring audits including education validation, code status validation for new/re-admissions, and orientation education.
- Completed audits titled 'Code staff education validation' observed.
- Licensed nurses received additional education on two nurses confirming the absence of vital signs and notifying the health care provider by telephone, not text, for orders and to clearly document in the medical record.
- Director of Nursing and Unit Manager designees began educating licensed nurses on evaluating residents for the absence of vital signs. Staff instructed that if vital signs are absent, they must follow the residents' Advanced Directive. For residents with DNR orders or if death occurs in the facility, the physician must be notified for further orders. Staff are also required to notify the DON when a resident is noted to be absent of vital signs. Education emphasized that, per the Nurse Practice Act, only a physician may pronounce death; a licensed nurse (RN or LPN) cannot do so.
- Nurses received an electronic copy of the education. Licensed nurses must complete the education prior to starting their next shift.
- Licensed nurses are required to sign the education acknowledgment sheet before working.
- Interviews conducted with CNAs working across all shifts to verify education related to their role during a Code Blue, the Stop, Think, and Perform process, resident rights, participation in Code Blue drills, and education on resident rights.
- Licensed nurses received additional education on two nurses confirming the absence of vital signs, notifying a physician by telephone, do not text for orders, and to clearly document in the medical record.
- Licensed nurses received additional education on confirming the absence of vital signs and for residents with a DNR order nurses are required to notify the physician or Medical Director for additional orders.
- Interviews conducted with licensed nurses working across all shifts to verify training and knowledge about the new policies and processes, completed code status competencies, and participation in code blue drills.
- In-service attendance signature sheets and a log of electronic communications reviewed, which confirmed that nurses received the in-service training about the new processes.
Failure to Honor Resident's DNR Order Resulting in Unwanted CPR
Penalty
Summary
The facility failed to honor a resident's Do Not Resuscitate (DNR) order, resulting in the initiation of Cardiopulmonary Resuscitation (CPR) against the resident's documented wishes. On the date of the incident, a registered nurse (RN) found the resident unresponsive and without a pulse. The RN instructed a certified nursing assistant (CNA) to call a code and began chest compressions. After performing two compressions, the RN was informed that the resident had a DNR order in place and discontinued CPR. The DNR order was present in the resident's medical record and in the code status binder at the nurses' station, and the resident's care plan clearly indicated the existence of a DNR order. The resident involved had significant medical conditions, including dementia with severe cognitive impairment, Type 2 Diabetes Mellitus, vascular implants, osteoarthritis, chronic kidney disease, anxiety, depression, insomnia, hypertension, and Hodgkin's Lymphoma. The resident's DNR order was fully executed and documented in both the electronic health record and the physical code status binder. Despite these clear directives, staff failed to verify the resident's code status before initiating CPR, which was contrary to the resident's end-of-life wishes and facility policy. Interviews with staff revealed gaps in training and knowledge regarding code status verification and DNR procedures. The RN involved reported that orientation did not include education on Code Blue or DNR procedures, nor was she trained on how to locate a resident's code status in the electronic health record. Other staff members confirmed that the code status was not checked prior to the initiation of CPR. Facility policy required verification of code status by two nurses before starting CPR, but this protocol was not followed, resulting in the resident's DNR wishes not being honored.
Removal Plan
- Audit of the code status binders to validate DNR forms are in the appropriate binder.
- Audit to verify residents' DNR forms are present in the electronic medical record, physician orders are in place, and care plans are reflective of residents' code status.
- Staff education instructing licensed nurses to evaluate residents for absence of vital signs, and if vital signs are absent, to follow residents' Advanced Directive. If the resident has DNR orders, notify the provider for further orders.
- Staff education on Abuse and Neglect, with emphasis on the importance of following residents' wishes regarding code status.
- Education completed by all staff, excluding those on leave from work.
- Process initiated for newly hired facility staff to receive the above education during orientation and prior to working any assignment.
- Quality Assurance and Performance Improvement (QAPI) committee meeting conducted with the Medical Director, Administrator, Director of Nursing, and Interdisciplinary team members to review adherence to policy and procedure for advance directives, code status in the electronic health record, code status binders, following physician orders, and results of the root cause analysis.
- QAPI committee reviewed the plan viability of the advance directives process, code process, code status binder process, and audit results.
- QAPI committee reviewed education completion rates for licensed nurses and all other staff; staff on leave will be educated upon return.
- QAPI committee discussed ongoing monitoring audits including education validation; all staff interviewed answered questions appropriately.
- Code Blue drills continue until all nursing staff participate.
- QAPI committee reviewed ongoing audits, including validation of code status for new/re-admissions and staff education during general orientation.
- QAPI committee continued review of ongoing monitoring audits including education validation, code status validation for new/re-admissions, and orientation education.
- Completed audits titled 'Code staff education validation' observed; no issues identified.
- Licensed nurses received additional education regarding two nurses confirming the absence of vital signs and notifying the health care provider by telephone, not text, for orders and to clearly document in the medical record.
- Director of Nursing and Unit Manager designees began educating licensed nurses on evaluating residents for the absence of vital signs. Staff instructed that if vital signs are absent, they must follow the residents' Advanced Directive. For residents with DNR orders or if death occurs in the facility, the physician must be notified for further orders. Staff are also required to notify the DON when a resident is noted to be absent of vital signs. Education emphasized that, per the Nurse Practice Act, only a physician may pronounce death; a licensed nurse (RN or LPN) cannot do so.
- All nurses received an electronic copy of the education. Licensed nurses are required to sign the education acknowledgment sheet before working.
- Verification of the facility's removal plan conducted by the survey team through interviews with CNAs and licensed nurses to verify education related to their role during a Code Blue, the Stop, Think, and Perform process, resident rights, participation in Code Blue drills, and education on resident rights.
- In-service attendance signature sheets and a log of electronic communications reviewed, which confirmed that nurses received the in-service training about the new processes.
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