Alhambra Healthcare & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Petersburg, Florida.
- Location
- 7501 38th Ave N, Saint Petersburg, Florida 33710
- CMS Provider Number
- 105712
- Inspections on file
- 23
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Alhambra Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to ensure that LPNs administering IV antibiotics, including through PICC lines, had the required IV therapy certification and documented competency. Several residents with wound infections and osteomyelitis had physician orders for IV Vancomycin, Cefepime, and Cefazolin, and MARs showed multiple IV doses documented by various LPNs whose IV certification status was either unknown, not provided, or explicitly lacking. Interviews confirmed that some LPNs were not IV certified or could not produce certificates, the ADON did not hold IV certification in the state, and the DON had to administer at least one IV antibiotic dose. In addition, one resident did not receive a scheduled morning dose of IV Cefazolin, despite a later dose already being scheduled.
Surveyors found that staff failed to follow infection prevention and control practices for multiple residents, including those on Enhanced Barrier Precautions and those with a PICC line and nebulizer treatments. A resident on Enhanced Barrier Precautions had trash receptacles in the room and bathroom without liners, including overflowing containers full of used gloves and isolation gowns placed near a roommate’s bed, and dirty linen was left on a chair with a blanket removed from the soiled pile to be reused. During care for this resident, a CNA provided care without wearing a required gown despite isolation signage. Another resident receiving nebulizer treatments and IV antibiotics via a PICC line had an exposed nebulizer mask and an opened saline flush left on a dirty nightstand, and the PICC dressing was not changed within the facility’s stated seven-day interval. A shared trash receptacle for this resident and a roommate was also placed under the resident’s wheelchair with PPE hanging over the edge, contrary to the facility’s written standard precautions policy.
A resident admitted from the hospital with multiple documented pressure injuries to the sacrum, buttocks, and gluteal folds did not receive timely and appropriate wound treatment. Admission records and physician orders required daily monitoring and every-shift skin observations but contained no specific wound care treatment orders, and nursing staff did not obtain such orders. During a skin assessment, the DON and an RN found a large open area with a dark center on the lower back and additional open areas on the lower buttocks/upper thighs, with drainage noted on the incontinence brief and no dressings in place despite the resident having arrived with dressings. The RN could not explain the absence of dressings, and the wound NP reported she had not been contacted to see the new admit sooner or to provide interim treatment guidance, contrary to the facility’s wound management policy requiring evidence-based treatments and physician-directed wound care.
Two residents with significant mobility and toileting needs did not consistently receive timely assistance with toileting and incontinence care, as documented in their care plans. Documentation and interviews revealed that staff often provided assistance only once per day or not at all during some shifts, and residents reported long waits for help, particularly at night.
A resident admitted with severe post-surgical pain did not receive prescribed hydrocodone in a timely manner due to delays in medication procurement and lack of documented efforts by staff. Additionally, discrepancies were found between the Medication Administration Record and the controlled substance log, with several doses not properly documented. Facility staff confirmed the lack of a clear policy for timely medication delivery and acknowledged inconsistencies in recordkeeping.
Surveyors found that multiple resident rooms and bathrooms were not maintained in a safe or sanitary condition, with issues such as missing caulking around commodes, soiled and discolored flooring, and stained privacy curtains. The Maintenance Director reported being behind on work orders, contributing to the ongoing deficiencies.
Two residents experienced ant infestations in their rooms, with ants observed near food debris and on a bathroom windowsill. Despite prior complaints and facility policy requiring documentation and prompt action, staff did not log the pest sightings or ensure targeted treatment, resulting in ongoing pest issues.
The facility did not document required notifications for room changes involving three residents. Record reviews and interviews confirmed that notifications and reasons for the room changes were not entered in the progress notes, as required by policy. The DON acknowledged the missing documentation and confirmed that the process for notifying residents and their representatives was not consistently followed.
Surveyors found that multiple medication carts contained undated and improperly labeled medications, including eye drops, inhalers, and oral medications. LPNs interviewed were inconsistent in their labeling practices, and some were unfamiliar with facility procedures. The DON confirmed that all medications should be labeled with the date opened and expiration date, as required by facility policy, but this was not consistently done.
The facility was found deficient in its Emergency Preparedness Program for failing to include procedures for sewage and waste disposal for all 56 residents. This was identified during a record review with the Maintenance Director and Regional Maintenance Consultant, who acknowledged the absence of such procedures. The issue was discussed with the facility's administration during an exit conference.
The facility failed to maintain its generator according to NFPA standards, lacking evidence of weekly inspections and monthly load testing prior to February 2025. This deficiency was acknowledged by the Maintenance Director and discussed during an exit conference.
The facility failed to maintain an exit door in the 100-wing corridor, as it had a sign stating "*DO NOT EXIT" "ALARM WILL SOUND!" and did not close and latch properly. This was observed during a tour with the Maintenance Director and Regional Maintenance Consultant, and acknowledged during an interview and exit conference. Photographic evidence was obtained, and the deficiency is cited under NFPA 101 standards.
The facility failed to maintain its commercial cooking hood and fire suppression system according to NFPA standards. It did not provide evidence of one required semi-annual fire suppression inspection for 2024 and lacked regular monthly kitchen quick check inspections. Additionally, the cooking hood was not grease-tight due to unsealed seams. These issues were acknowledged by the facility's maintenance staff and discussed during the exit conference.
The facility failed to comply with NFPA 101 standards for the installation of alcohol-based hand rub (ABHR) dispensers. During a facility tour, it was found that dispensers in the employee lounge and corridor were installed within one inch of ignition sources, such as light switches and receptacles. These findings were acknowledged by the Maintenance Director and reviewed with the facility's administration.
The facility failed to maintain two duct smoke detectors according to NFPA 101 standards. The required annual duct detector differential pressure testing was not conducted, with the last test dated over a year ago. Additionally, biennial sensitivity testing was not documented. These deficiencies were acknowledged by the Maintenance Director and discussed with the Administrator.
The facility failed to maintain its automatic fire sprinkler system according to NFPA 101 standards. A cable was improperly zip-tied to the fire sprinkler piping, and a sprinkler in the medical records storage room contained foreign material. These issues were identified during an inspection and acknowledged by the facility's maintenance staff.
The facility did not conduct fire drills as required by NFPA 101, failing to provide evidence for one drill in the third quarter and two drills in the fourth quarter of 2024 across various shifts. This was acknowledged by the Maintenance Director and discussed with the Administrator.
An oxygen cylinder in a transport cart was found unsecured during a facility tour, violating NFPA 99 standards. The Maintenance Director and Regional Maintenance Consultant acknowledged the deficiency, which was reviewed with the Administrator during the exit conference. Photographic evidence was obtained.
The facility did not post up-to-date nurse staffing information on one observed day. On that day, the posted information was outdated by two days, failing to meet the facility's policy of daily updates. The policy requires posting the facility name, current date, and staffing details for RNs, LPNs, and CNAs in a clear format accessible to residents and visitors.
The facility failed to maintain professional standards for food service safety, with issues in food storage, labeling, and cleanliness. Observations revealed improperly stored and labeled food items, including vegan bacon without a use-by date, spoiled produce, and moldy lemons and limes. The dish machine was found with crumbs and rust, and the dining room refrigerator contained unlabeled resident food. Interviews indicated that staff responsibilities for storage and labeling were not consistently followed, despite policy guidelines.
The facility did not comply with staffing standards by failing to update the nurse staffing information on the East Wing. Observations showed that the staffing board remained unchanged throughout the day, displaying only limited staff names without room numbers or shift data. This non-compliance with the facility's policy and state regulations hindered transparency and accessibility of staffing information for residents and the public.
The facility failed to complete Level II PASRR evaluations for several residents with serious mental illnesses and neurocognitive disorders, as required by guidelines. Despite indications from Level I screens, necessary evaluations were not conducted, and staff interviews revealed a lack of awareness about the requirement.
The facility did not maintain a safe and homelike environment in two resident rooms. In one room, a resident reported a broken armoire drawer, and in another, the toilet base was unsecured. Staff failed to place work orders for these issues, and the facility could not provide a maintenance policy. Photographic evidence was obtained.
The facility failed to develop individualized care plans for two residents, one with PTSD and another with end-stage renal disease. The care plans lacked specific interventions and updates, leading to deficiencies in addressing their needs. Staff were unaware of the PTSD triggers for one resident, and the dialysis care plan for the other was incomplete. The facility's policies emphasize comprehensive, person-centered care plans, but these were not met.
A facility failed to identify PTSD triggers and develop an individualized care plan for a resident with PTSD. The resident's care plan mentioned the risk of re-traumatization but lacked specific interventions. Staff interviews revealed a lack of awareness and training regarding PTSD triggers. The facility's policy emphasized culturally sensitive care, but implementation was lacking.
The facility did not ensure a safe, clean, and homelike environment in two resident rooms. In one room, a resident reported a broken armoire drawer, and in another, the toilet base was unsecured. Staff confirmed the issues, but no work orders were placed, and the facility lacked a maintenance policy.
Failure to Ensure LPN IV Certification and Proper Administration of IV Antibiotics
Penalty
Summary
The deficiency involves the facility’s failure to ensure that LPNs had the required IV therapy certification and documented competency to administer IV medications, including through PICC (a type of central venous catheter), for multiple residents. Florida Board of Nursing requirements cited in the report specify that LPNs may perform IV therapy only after appropriate education and training, including a minimum of four hours of instruction with didactic and clinical components, and facility-determined competency. Despite these requirements, several LPNs either lacked IV certification, had not provided proof of certification, or had incomplete documentation of their IV training while still being associated with residents receiving IV antibiotics. For one resident with an infected left foot and a PICC line, physician orders included Cefepime IV every 12 hours for several weeks and Vancomycin IV once daily. The MAR showed multiple IV antibiotic administrations documented by various LPNs, including entries by LPNs later identified as not IV certified or unable to produce IV certification (e.g., Staff B, C, E, J, L, and others). Interviews revealed that one LPN assigned to this resident stated she was new, had not provided her IV course certificate, and could not administer the ordered IV antibiotic; the ADON also stated she did not have an IV certificate in Florida and that the DON would administer the IV antibiotic. Another LPN reported she had taken an IV course a year prior but never received a certificate and would need to contact the organization that provided the course, despite having been employed at the facility for nearly a year. For another resident with wound infection requiring Vancomycin IV and a third resident with osteomyelitis requiring Cefazolin IV three times daily, physician orders and MARs showed multiple IV antibiotic administrations documented by LPNs whose IV certification status was not verified or was explicitly reported as lacking. The MAR for the resident with Vancomycin showed several IV doses signed out by different LPNs, and the MAR for the resident with Cefazolin showed numerous IV doses documented by multiple LPNs, including agency staff. During an interview, facility leadership confirmed that one resident had not received a scheduled morning dose of Cefazolin, even though the next dose was already scheduled for later that day. Overall, observations, interviews, and record review demonstrated that the facility did not ensure LPNs administering IV medications, including via PICC lines, were appropriately IV certified and that IV therapy was administered as ordered.
Infection Control Failures with PPE Use, Device Care, and Waste Handling
Penalty
Summary
Surveyors identified multiple failures in the facility’s infection prevention and control practices involving residents on Enhanced Barrier Precautions and those receiving respiratory treatments and IV therapy. For one resident on Enhanced Barrier Precautions due to a right nephrostomy and indwelling suprapubic catheter, surveyors observed small trash receptacles in the room and bathroom without disposable liners, including one receptacle containing used gloves, gowns, and other garbage. Later observations showed an overflowing trash receptacle without a liner, full of doffed gloves and isolation gowns, positioned near the roommate’s bed as the roommate and a family member entered the room. Dirty linen was also observed tossed on a chair, with a blanket removed from the soiled linen pile to be returned to the resident. During care for this same resident, an unidentified CNA provided care while the resident was on Enhanced Barrier Precautions but was not wearing a gown despite appropriate signage posted on the door. For another resident receiving respiratory treatments and IV antibiotics via a PICC line, surveyors observed an exposed nebulizer mask left out on a dirty nightstand surface, along with an opened normal saline flush that was not properly stored. The resident’s PICC line dressing was labeled with a date indicating it had not been changed within the facility-stated seven-day interval, and the DON acknowledged that the dressing should have been changed the previous day. After IV antibiotic administration and PICC dressing observation, the trash receptacle for this resident and the roommate was found placed in front of the resident’s footboard under the wheelchair, with PPE hanging over the edge. These observations occurred despite a facility policy on Standard Precautions Infection Control that requires appropriate PPE use, proper handling and disposal of contaminated equipment and materials, and staff training on infection prevention procedures.
Failure to Provide Timely Wound Treatment for Existing Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate treatment and services for existing pressure ulcers for one resident. The resident reported being admitted from the hospital with sores on his bottom and stated he had not received a bath or shower and could not recall if his wounds had been addressed. The admission documentation (3008 Section T and initial skin assessment dated 02/27/2026) identified multiple pressure wounds on the sacrum, bilateral buttocks, and gluteal folds with specific measurements. Physician orders dated 02/27/2026 included daily monitoring of the sacral wound with documentation of dressing presence and status, surrounding skin condition, possible complications, and pain, as well as every-shift skin observations and Enhanced Barrier Precautions. However, there were no physician orders for actual wound care treatments such as cleansing method, type of dressing, or frequency of dressing changes. During a head-to-toe skin assessment on 03/03/2026 with the DON, the resident was observed wearing incontinence briefs with small areas of drainage and no wound dressings present for removal. The DON observed a large open area on the lower back approximately palm-sized with a dark black area in the center, and small open areas on the left and right lower buttocks/upper thigh areas. The DON and an RN then cleansed the wounds with normal saline and applied large bordered dressings. The RN later stated she recalled the resident arriving with dressings in place but could not explain why there were no dressings at the time of the observation, and confirmed she is the designated nurse assisting the wound NP on weekly wound rounds. The wound NP reported she makes rounds weekly, relies on the facility to email new admits or readmits to be seen, had received no communication requesting an earlier visit or guidance for this resident, and understood she was to see the resident on her normal weekly rounds. The facility’s wound treatment management policy requires that wound treatments be provided per physician orders and that, in the absence of treatment orders, the licensed nurse notify the physician to obtain them, which did not occur for this resident’s pressure wounds.
Failure to Provide Consistent Toileting Assistance for Residents
Penalty
Summary
The facility failed to provide adequate care and services for activities of daily living, specifically toileting assistance, for two residents. One resident, admitted with peripheral vascular disease and chronic obstructive pulmonary disease, required assistance with ambulation and toileting due to recent arterial bypass surgery and significant pain. Despite care plans and assessments indicating the need for staff assistance with toileting and incontinence care, documentation showed inconsistent provision of these services. The resident reported being left in feces and urine for hours at night, and records indicated that toileting assistance was documented only once per day on several occasions, rather than at least once per shift as expected. Another resident, with diagnoses including heart failure and decreased mobility, also required hands-on assistance with toileting. Over a 29-day period, documentation revealed that toileting assistance was provided only 56 times across 87 shifts, with some days showing only one instance of assistance or none at all. The resident confirmed delays in staff response to call bells, sometimes waiting 30-40 minutes or not receiving assistance at all. Care plans for both residents included interventions for toileting and incontinence care, but the documented care did not align with these plans. Interviews with staff, including the Medical Records manager and the DON, confirmed the lack of consistent documentation and provision of toileting assistance. The DON acknowledged that records reflected toileting assistance being provided only once per day for one resident. These findings demonstrate a failure to ensure that residents received timely and adequate assistance with toileting and incontinence care as required by their care plans and clinical needs.
Failure to Ensure Timely Pain Medication Procurement and Accurate Controlled Substance Documentation
Penalty
Summary
The facility failed to ensure timely procurement of pain medication and accurate accounting of controlled substances for a resident admitted with significant pain following an arterial bypass surgery. Upon admission, the resident reported severe pain and was unable to walk due to surgical incisions with staples in place. Despite a physician's prescription for hydrocodone being signed prior to admission and faxed on the day after admission, there was no documentation of efforts by the facility to obtain the medication from the time of admission until more than 24 hours later, resulting in a delay in pain management. Review of the resident's records showed ongoing reports of moderate to severe pain, with pain levels frequently documented as 7 or higher on a 10-point scale. The Medication Administration Record (MAR) and the Medication Monitoring Control Record for hydrocodone did not match, with several instances where withdrawals of the medication were not documented on the MAR. The facility's policy required that the dose noted on the usage form or dispensing system must match the dose recorded on the MAR and controlled drug record, but this was not followed in this case. Interviews with facility staff, including the DON and pharmacy consultant, confirmed that medications for new admissions should be received by the next pharmacy delivery and that documentation should be consistent between records. However, the facility lacked a policy and procedure for timely medication procurement, and staff acknowledged the discrepancies between the MAR and control records. These failures resulted in both a delay in pain medication administration and inaccurate accounting of controlled substances for the resident.
Failure to Maintain Safe, Sanitary, and Comfortable Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, sanitary, and comfortable homelike environment in 6 out of 16 resident rooms inspected. Specific deficiencies included absent caulking around commodes, discoloration and uncleanliness on commodes, unclean and soiled flooring in resident rooms and bathrooms, and visible discoloration on privacy curtains. In several rooms, the commodes lacked proper caulking at the base, and the surrounding flooring was noted to be darker, sticky, or heavily soiled with various discolorations. One privacy curtain was observed to have a dark brownish-red discoloration in the shape of a T, along with additional spots. In another instance, the commode had brownish marks on the outside, heavy discoloration at the floor juncture, and dried reddish-brown matter under the toilet seat. Additionally, a detached corner molding was found laying on the hallway floor at the entrance to the 100 hall. During an interview, the Maintenance Director, who had been employed for seven weeks, stated he was still addressing work orders that predated his employment. The observations and interviews confirm that the facility did not ensure a consistently clean, safe, and comfortable environment for residents, staff, and the public in the areas inspected.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of ants in the rooms of two residents. During a facility tour, a line of tiny ants was observed crawling on the floor next to a resident's nightstand, where food debris was also present. The resident confirmed having seen ants on his bed. Another resident reported seeing ants in his bathroom by the window, and observation confirmed a line of ants just below the windowsill. The resident stated he had reported the issue previously, but the ants persisted. Interviews with facility staff revealed that the pest control company visits every other Friday and as needed, but complaints about bugs and a rodent in the attic had been ongoing. Review of pest control invoices showed recent treatments focused on exterior areas, kitchen, and common spaces, with no specific mention of ant treatment in the affected rooms. The Environmental Service Manager acknowledged receiving complaints about ants and observing them in a resident's room due to food on the floor, but did not document the sighting in the pest logbook as required by facility policy. The facility's pest control policy mandates maintaining a report system for pest issues between scheduled visits, which was not followed in this instance.
Failure to Document Resident Room Change Notifications
Penalty
Summary
The facility failed to document notifications of room changes for three residents, as required by resident rights regulations. Record reviews showed that one resident changed rooms multiple times, but notifications of these changes were not documented in the progress notes for several of the moves. Similarly, two other residents experienced room changes, and there was no documentation in their progress notes indicating that they or their representatives were notified of the changes or the reasons for them. The Director of Nursing (DON) confirmed during interviews that the Social Services Director (SSD) is responsible for notifying families and that nursing staff complete the transfers, but acknowledged that documentation of these notifications was missing for the affected residents. The facility's policy on resident rights, which includes the right to be informed about room changes, was not followed in these instances. The DON reviewed the records and confirmed the lack of documentation for the required notifications and reasons for the room changes. The absence of these records indicates that the facility did not consistently honor the residents' rights to receive written notice before a room change was made.
Failure to Properly Label and Store Medications in Medication Carts
Penalty
Summary
Surveyors observed that medications and biologicals in three medication carts were not labeled or stored according to facility policy and professional standards. Specifically, undated used bottles of Latanoprost eye drops, Breo inhalers, and a Combivent inhaler were found in one cart, with packaging indicating expiration periods after opening but lacking any opening dates. Another cart contained an opened bottle of Ibuprofen without an opening date, which was only labeled after the surveyor's observation. A third cart had an undated empty bottle of Omeprazole, undated used bottles of Latanoprost, Loteprednol, and Timolol eye drops, and an undated used Breo inhaler, again with no indication of when these medications were opened. Interviews with LPNs revealed a lack of consistent practice in labeling medications upon opening, and one LPN was unfamiliar with the facility's pharmacy procedures due to being new. The DON confirmed that all medications should be labeled with the date opened and expiration date, and acknowledged the presence of agency staff as a contributing factor. A review of facility policies showed clear requirements for labeling medications with opening and expiration dates, and for removing outdated or improperly labeled medications from inventory. The policies also specified that certain medications require a shorter expiration period once opened, and that any medication found without a date should default to the date dispensed. Despite these policies, the observed medication carts contained multiple items that were not labeled as required, indicating a failure to follow established procedures for medication labeling and storage.
Deficiency in Emergency Preparedness: Lack of Sewage and Waste Disposal Procedure
Penalty
Summary
The facility failed to incorporate procedures for sewage and waste disposal into their Emergency Preparedness Program (EPP) for all 56 residents. This deficiency was identified during a record review conducted with the Maintenance Director and the Regional Maintenance Consultant. The review took place on March 31, 2025, between 9:30 a.m. and 1:30 p.m. During this review, it was found that the facility did not have a procedure in place for sewage and waste disposal in the event of a system loss. An interview with the Maintenance Director and the Regional Maintenance Consultant confirmed the absence of this procedure. These findings were subsequently discussed with the Administrator, the Maintenance Director, and the Regional Maintenance Consultant during an exit conference held on the same day between 4:15 p.m. and 4:30 p.m. The lack of a sewage and waste disposal procedure is a violation of the Code of Federal Regulations, specifically 42 CFR § 483.73(b)(1)(D).
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the accuracy of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted to comply with the requirements set forth under state and federal laws and agencies. 1. The QA & A committee will review to approve the procedure for sewage and waste disposal on 4/24/2025. 2. No other areas or residents were affected by deficient practice. 3. Education provided to the Maintenance Director by NHA or designee on procedures for sewage and waste disposal by 4/24/2025. 4. All policies and procedures will be reviewed and monitored annually by the QA & A committee.
Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its generator in accordance with NFPA 99 and NFPA 101 standards. During a record review conducted with the Maintenance Director and the Regional Maintenance Consultant, it was found that the facility did not have evidence of weekly visual inspections of the generator prior to February 2025. Additionally, the facility lacked documentation of the monthly load testing of the generator for the same period. These deficiencies were acknowledged by the Maintenance Director and the Regional Maintenance Consultant during the review. The findings were discussed with the Administrator, the Maintenance Director, and the Regional Maintenance Consultant during an exit conference. The absence of records for the required inspections and testing indicates a failure to comply with the necessary maintenance and testing protocols as outlined in NFPA 99 and NFPA 101. This oversight could potentially impact the facility's ability to ensure the generator's readiness and reliability in providing essential power during emergencies.
Plan Of Correction
1. The Maintenance Director in charge of oversight of generator weekly and monthly testing in 2024 is no longer with the facility. The new Maintenance Director is in compliance with weekly and monthly testing of generator. 2. No other areas or residents were affected by deficient practice. 3. Education was provided to the Maintenance Director by NHA on 4/17/2025 on maintaining the generator in accordance with NFPA 99. 4. Results of the weekly and monthly generator testing will be reported to the QA&A committee and reviewed monthly.
Exit Door Deficiency in 100-Wing Corridor
Penalty
Summary
The facility failed to maintain one of two exits in the corridor of the 100-wing, as observed during a tour conducted by the Maintenance Director and the Regional Maintenance Consultant. The exit door located by resident room 102 had a sign posted on it stating "*DO NOT EXIT" "ALARM WILL SOUND!" Additionally, the exit door did not close and latch properly when tested, which is a violation of the NFPA 101 Life Safety Code requirements. These findings were acknowledged by the Maintenance Director and the Regional Maintenance Consultant during an interview conducted concurrently with the record review. The deficiency was further discussed with the Administrator, the Maintenance Director, and the Regional Maintenance Consultant during the exit conference. Photographic evidence was obtained to document the deficiency, which is cited under NFPA 101 (2012 and 2021 Editions) sections 19.2.1, 19.2.2.2, 7.1.10.1, 7.1.10.2.1, and 7.2.1.4.5.
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the accuracy of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted to comply with the requirements set forth under state and federal laws and agencies. 1. The sign was removed from the exit door on 3/31/2025 located by resident room 102 by maintenance staff. The door that failed to latch was repaired by Regional Maintenance Consultant on 3/31/2025 and the door now closes and latches appropriately. 2. Exit doors in facility were audited for removal of any do not exit signs and to ensure doors close and latch by Maintenance Director on 04/01/2025. 3. Education was provided to the Maintenance Director on Means of Egress Requirements. The Maintenance Director or designee will conduct quality assurance checks weekly for 12 weeks ensuring no exit signs on exit doors and doors closing and latching appropriately. 4. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured. Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the accuracy of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted to comply with the requirements set forth under state and federal laws and agencies. 1. The sign was removed from the exit door on 3/31/2025 located by resident room 102 by maintenance staff. The door that failed to latch was repaired by Regional Maintenance Consultant on 3/31/2025 and the door now closes and latches appropriately. 2. Exit doors in facility were audited for removal of any do not exit signs and to ensure doors close and latch by Maintenance Director on 04/01/2025. 3. Education was provided to the Maintenance Director on Means of Egress Requirements. The Maintenance Director or designee will conduct quality assurance checks weekly for 12 weeks ensuring no exit signs on exit doors and doors closing and latching appropriately. 4. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Deficiencies in Cooking Hood Maintenance and Fire Suppression Inspections
Penalty
Summary
The facility failed to maintain compliance with NFPA 101 and NFPA 96 standards regarding the maintenance of its commercial cooking hood and fire suppression system. During a record review, it was discovered that the facility did not provide evidence of one of the two required semi-annual inspections of the fire suppression system for the year 2024, with the only available inspection dated January 9, 2024. Additionally, the facility failed to conduct the 8-point monthly kitchen quick check inspection regularly, as the only record available was from March 2025. These lapses were acknowledged by the Maintenance Director and the Regional Maintenance Consultant during the review. Furthermore, during a facility tour, it was observed that the commercial cooking hood was not grease-tight, as the seams of the hood were not properly sealed. This deficiency was also acknowledged by the Maintenance Director and the Regional Maintenance Consultant. These findings were discussed with the Administrator, the Maintenance Director, and the Regional Maintenance Consultant during the exit conference, and photographic evidence was obtained to document the issues.
Plan Of Correction
1. Education was provided to the Maintenance Director on ensuring the two semi-annual inspections of the fire suppression system are completed, completing the monthly 8-point kitchen quick check by NHA on 4/1/2025. The commercial cooking hoods seams were resealed to be made grease tight on 04/01/2025 by the Maintenance Director. 2. No other areas or residents were affected by deficient practice. 3. Education was provided to the Maintenance Director by the NHA on 4/1/2025 on ensuring the two semi-annual inspections of the fire suppression system are completed, completing the 8-point monthly kitchen quick check and ensuring the commercial cooking hood seams are sealed and grease tight. The Maintenance Director will conduct quality assurance checks on the commercial cooking hood to ensure seams are sealed and grease tight weekly for 12 weeks. 4. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Non-compliant Installation of ABHR Dispensers
Penalty
Summary
The facility failed to install alcohol-based hand rub (ABHR) dispensers in accordance with NFPA 101 standards in one of its three smoke compartments. During a facility tour conducted with the Maintenance Director and the Regional Maintenance Consultant, it was observed that an ABHR dispenser in the employee lounge was installed within one inch of an ignition source, specifically a light switch or receptacle. Additionally, another ABHR dispenser located in the corridor across from the water heater room was also installed within one inch of an ignition source, a receptacle. These findings were acknowledged by the Maintenance Director and the Regional Maintenance Consultant during the tour. The observations were subsequently reviewed with the Administrator, the Maintenance Director, and the Regional Maintenance Consultant during the exit conference. The report indicates that these installations do not comply with the safety requirements outlined in NFPA 101, which stipulate that dispensers should not be installed within one inch of an ignition source.
Plan Of Correction
1. The ABHR dispenser located in the employee lounge was moved by Maintenance Director on 4/1/2025 and is no longer installed within 1 of an ignition source. The ABHR dispenser located in the corridor across from the water heater room was moved by Maintenance Director on 4/1/2025 and is no longer installed within 1 of an ignition source. 2. An audit was completed by Maintenance Director on 4/17/2025 to ensure all ABHR dispensers are not within 1 of an ignition source. No additional findings noted. 3. Education was provided to the Maintenance Director by NHA on ensuring ABHR dispensers are installed in accordance with NFPA 101 on 4/1/2025. Quality assurance checks will be completed quarterly ongoing at an integrated facility preventive maintenance program. 4. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly to ensure continued compliance.
Failure to Maintain Duct Smoke Detectors
Penalty
Summary
The facility failed to maintain two duct smoke detectors in accordance with NFPA 101 standards. During a record review with the Maintenance Director and the Regional Maintenance Consultant, it was found that the facility did not provide evidence of the required annual duct detector differential pressure testing for the two duct detectors. The most recent testing available was from March 21, 2023, indicating that the annual testing had not been conducted as required. Additionally, the facility did not provide evidence of the biennial sensitivity testing for the two duct smoke detectors. These deficiencies were acknowledged by the Maintenance Director and the Regional Maintenance Consultant during the record review and were discussed with the Administrator during the exit conference. The lack of proper testing and maintenance records for the duct smoke detectors constitutes a failure to comply with the NFPA 101 and NFPA 72 standards.
Plan Of Correction
1. The annual duct detector differential pressure testing for both duct detectors was completed on 2/3/2025 and 3/31/2025. The biennial sensitivity testing for both duct smoke detectors was completed on 03/24/2025. 2. No other areas or residents were affected by deficient practice. 3. Education was provided to the Maintenance Director regarding maintaining the duct detector differential pressure testing and biennial sensitivity testing for both duct smoke detectors per NFPA 101 by NHA on 4/17/2025. 4. Results from the annual duct detector differential pressure testing for both duct detectors and the biennial sensitivity testing for both detectors will be reported to the QA&A committee.
Fire Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its automatic fire sprinkler system in accordance with NFPA 101 standards. During a facility tour, it was observed that a cable related to the facility's satellite system was improperly zip-tied to the fire sprinkler piping located on the exterior of the building. This improper attachment was connected to the fire riser piping, which is a violation of the maintenance standards for fire protection systems. Additionally, a sprinkler located in the medical records storage room was found to contain foreign material, further indicating a lack of proper maintenance and inspection. These deficiencies were identified during an inspection conducted by the Maintenance Director and the Regional Maintenance Consultant. The findings were acknowledged by both the Maintenance Director and the Regional Maintenance Consultant during the inspection and were subsequently reviewed with the Administrator during the exit conference. Photographic evidence was obtained to document these deficiencies, which were found to be in violation of the NFPA 101 and NFPA 25 standards for the inspection, testing, and maintenance of water-based fire protection systems.
Plan Of Correction
1. The Maintenance Director removed the zip tie from the cable related to the facility's satellite system on 4/9/2025. The sprinkler in the medical records storage room was serviced and cleaned by Maintenance staff on 04/2/2025. 2. The Maintenance Director conducted a quality assurance check on sprinkler heads on 4/18/2025. 3. Education was provided to the Maintenance Director by NHA on 4/17/2025 regarding maintaining the automatic fire sprinkler system in accordance with NFPA 101. Ongoing monthly quality assurance checks will be completed by the Maintenance Director or designee on facility sprinkler heads as a part of the facility preventive maintenance program. 4. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly to ensure continued compliance.
Failure to Conduct Required Fire Drills
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101 standards, as evidenced by the absence of documentation for required fire drills. During a record review with the Maintenance Director and the Regional Maintenance Consultant, it was found that the facility did not provide evidence of one of the three required fire drills during the third quarter of 2024 for the second shift. Additionally, there was no evidence of two of the three required fire drills during the fourth quarter of 2024 for the first and third shifts. These findings were acknowledged by the Maintenance Director and the Regional Maintenance Consultant during the record review and were further discussed with the Administrator during the exit conference. The lack of documentation for these fire drills indicates a failure to comply with the established routine of conducting fire drills at unexpected times under varying conditions, as required by NFPA 101.
Plan Of Correction
1. The Maintenance Director in charge of oversight of fire drills in 2024 is no longer with the facility. A fire drill was conducted on each shift of the three shifts during the first quarter of 2025 by the new Maintenance Director. 2. No other areas or residents were affected by deficient practice. 3. Education was provided to the new Maintenance Director by NHA on 4/17/2025 on the requirement to conduct fire drills in accordance with NFPA 101. Monthly audits will be conducted by the Maintenance Director or designee to ensure fire drills are conducted on each of the three shifts monthly. 4. Results from the fire drills will be reported to and reviewed by the QA&A committee.
Unsecured Oxygen Cylinder in Transport Cart
Penalty
Summary
The facility failed to manage an oxygen cylinder in accordance with NFPA 99 standards. During a facility tour conducted by the Maintenance Director and the Regional Maintenance Consultant, it was observed that an e-size oxygen cylinder in a transport cart was unsecured. The cylinder was not properly secured to the cart, which is a violation of the safety standards outlined in NFPA 99. The observations were confirmed through an interview with the Maintenance Director and the Regional Maintenance Consultant, who acknowledged the findings. These findings were subsequently reviewed with the Administrator, the Maintenance Director, and the Regional Maintenance Consultant during the exit conference. Photographic evidence was obtained to document the unsecured oxygen cylinder, further substantiating the deficiency.
Plan Of Correction
1. The e-size oxygen cylinder in transport cart was secured on 03/31/2025 by the Maintenance Director. 2. The Maintenance Director conducted quality assurance check on e-size oxygen cylinders in transport carts to ensure they were secured on 4/1/2025 and no additional findings notes. 3. Education was provided to facility staff on securing e-size oxygen cylinder in transport securely by the NHA or designee by 4/25/2025. The Maintenance Director, or designee, will conduct weekly for 12 weeks audit on 5 random e-size oxygen cylinders in transport carts to ensure they are secured. 4. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Failure to Post Up-to-Date Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that up-to-date nurse staffing information was posted on one of the three days observed by surveyors. On March 24, 2025, at 9:00 AM, the posted staffing information was dated March 22, 2025, with a resident census of 60, indicating that the information was not current. By 10:12 AM on the same day, the staffing posting had still not been updated. The facility's policy, dated November 19, 2019, requires that staffing information, including the facility name, current date, total number, and actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides, be posted daily at the beginning of each shift in a clear and readable format in a prominent place accessible to residents and visitors. The facility is also required to maintain this data for a minimum of 18 months. Photographic evidence was obtained to support these findings.
Plan Of Correction
1. Re-education provided to staffing coordinator by NHA on requirement to post nurse staffing information daily on. 2. No other areas or residents were affected by deficient practice. 3. Reeducation by NHA on was provided to IDT team on requirement for posting up-to-date staffing information daily. 4. The administrator or designee will complete quality assurance check weekly 5X a week for 6 weeks then 3X a week for an additional 6 weeks to ensure up-to-date staffing information is posted daily. 5. All results of the quality assurance checks/audits will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations of improper food storage, labeling, and cleanliness in the kitchen and dining areas. During an initial tour of the kitchen, pliers were found on the dish machine base, and the machine itself had crumbs and food particles on top, with signs of rust on the hood. In the walk-in cooler, vegan bacon was found without a use-by date, and lettuce and potatoes were observed with spoilage and bio growth, respectively. The reach-in refrigerator contained lemons and limes with mold, and a stick of butter was improperly sealed. In the dining room refrigerator/freezer, a food item was labeled with a resident's name but lacked a date, and two ice cream packages were found without any resident identification. The Director of Nursing could not confirm the duration of the food's presence. Interviews with the Kitchen Manager and Certified Dietary Manager revealed that the dish machine's cleanliness was overlooked, and the maintenance staff had left the pliers. The Kitchen Manager stated that all staff are responsible for proper storage, labeling, and dating, and that these topics were discussed in monthly meetings. The facility's policies on labeling, dating, and food storage were reviewed, indicating that leftovers and opened foods should be labeled with a discard date, and food items should be used on a first-in, first-out basis. However, the observations and interviews revealed that these policies were not consistently followed, leading to the deficiencies noted in the report.
Plan Of Correction
1. On the following was completed by kitchen manager: The pliers with a red handle on the machines base in the dish machine area were removed. The top area of the dish machine was cleaned. The dish machine hood was cleaned. The bacon strips in clear storage bag were discarded. The lettuce was discarded. The potatoes were discarded. In refrigerator #2 the lemon and limes and stick of butter were discarded. All items that did not belong to residents with name and date were discarded from dining room refrigerator. 2. Regional dietary manager conducted sanitation and quality audit of facility kitchen on. No other findings were identified. 3. Re-education was provided by Regional Dietary Manager to Kitchen Manager and dietary staff on storage, labeling and dating of food as well as kitchen sanitation. Reeducation was provided to maintenance staff on ensuring tools/equipment are removed from any area if not being actively worked on. Quality assurance checks for sanitation and for proper food storage, labeling and dating will be completed by the Kitchen Manager or designee weekly 3X for 12 weeks. 4. All results of the quality assurance checks/audits will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Failure to Post Nurse Staffing Information on East Wing
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in a manner that was beneficial to residents and the public on the East Wing of the facility. According to the facility's policy, staffing information, including the facility name, current date, total number, and actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides, as well as the resident census, should be posted daily at the beginning of each shift in a clear and readable format. This information should be placed in a prominent location that is readily accessible to residents and visitors. However, during observations at 10:12 AM and 5:45 PM, the staffing board on the East Wing was found to be unchanged, displaying only two nursing staff names and three Certified Nursing Assistant staff names for the 7 AM to 3 PM shift, with no room numbers or shift data posted. The facility's policy also requires that the posted nurse staffing data be maintained for a minimum of 18 months or as required by state law, whichever is greater. Additionally, the facility must make nurse staffing data available to the public upon request. The failure to update the staffing board as required by the facility's policy and state regulations indicates non-compliance with the staffing standards, which are intended to ensure transparency and accessibility of staffing information for the benefit of residents and the public.
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the accuracy of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted to comply with the requirements set forth under state and federal laws and agencies. 1. Re-education provided to East wing nurse from 7am-3pm and East wing nurse from 3pm-11pm by NHA on the requirement to post nurse staffing information in a way to benefit the residents and public. 2. No other areas or residents were affected by deficient practice. 3. Reeducation was provided to nursing staff by DON or designee on requirement for posting up-to-date staffing information daily. 4. The Director of Nursing or designee will complete quality assurance check weekly 5X a week for 6 weeks then 3X a week for an additional 6 weeks to ensure up-to-date staffing information is posted daily. 5. All results of the quality assurance checks/audits will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Failure to Complete Level II PASRR Evaluations
Penalty
Summary
The facility failed to ensure that a Level II Pre-Admission Screening and Resident Review (PASRR) was completed for five residents who were sampled. These residents had various diagnoses, including serious mental illnesses and neurocognitive disorders, which necessitated a Level II PASRR evaluation according to the guidelines. However, the facility did not complete these evaluations, as evidenced by the records and interviews conducted during the survey. Resident #48 was admitted with diagnoses including PTSD, unspecified dementia, and substance abuse, with major depressive disorder added later. The Level I PASRR screen indicated the need for a Level II evaluation due to the presence of a serious mental illness alongside dementia, but this was not completed. Similarly, Resident #29, diagnosed with paranoid schizophrenia and other mental health conditions, did not receive a Level II PASRR despite the chronic nature of their mental illness. Other residents, such as Resident #6, #13, and #2, also had significant mental health diagnoses that warranted a Level II PASRR evaluation. These included conditions like dissociative identity disorder, bipolar disorder, and schizoaffective disorder. The facility's policy required that such evaluations be conducted when indicated by the Level I screen, but the necessary referrals and evaluations were not made. Interviews with the Social Services Director and Director of Nursing revealed a lack of awareness regarding the need to complete these evaluations, contributing to the oversight.
Plan Of Correction
1. Social services director submitted a Level II PASRR request for resident #48 on #13, resident #29 on, resident #6 on, and #2 on. 2. The Social services director will audit residents who have a diagnosis of SMI, ID, and/or related in the facility and if warranted, will submit for level 2 PASRR screen by. 3. Reeducation was provided to the IDT team on the Level II PASRR screen process by NHA or designee on. Ongoing, new admissions to the facility with diagnosis of SMI, ID, and/or related will be audited by social services director or designee within 72 hours of admission for presence of level 2 PASRR screen and submit if warranted. IDT will conduct quality assurance check weekly for 12 weeks on provider documentation to identify any additional diagnoses requiring a level 2 PASRR screen to be initiated. 4. All results of the quality assurance checks/audits will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, and homelike environment in two resident rooms, specifically rooms #201 and #214. In room #201, a resident reported that the dark brown armoire's drawer was broken and could not be opened, which had been an issue for some time. The observation confirmed that the face of the top drawer was separated from the rest of the drawer on the left side. In room #214, the toilet base was not secured to the floor, and both residents in the room confirmed they used the toilet. Staff D, a Certified Nursing Assistant, stated that a work order should be placed in the facility's electronic work order system if repairs are needed, but no such order was found for these issues. The Housekeeping Director stated that housekeeping cleans the bathrooms daily and would inform the Maintenance Director of any repairs needed, as housekeeping staff do not have access to the work order system. However, the Maintenance Director confirmed not having received any work orders for the issues in rooms #201 and #214. The facility was unable to provide a policy for Building/Equipment Maintenance when requested. Photographic evidence was obtained to support these findings.
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the accuracy of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted to comply with the requirements set forth under state and federal laws and agencies. 1. The armoires drawer in was repaired on by the maintenance director. The toilet base in was secured to the floor on by the maintenance director. 2. Quality assurance check of all residents armoires and toilets was completed on by maintenance director. No additional findings were noted. 3. Facility staff received education on utilizing the TELS system for work orders by NHA or designee by . 4. Quality assurance checks on armoires and toilets will be completed by IDT members 3x a week for 6 weeks then 1x a week for an additional 6 weeks. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop an individualized care plan for two residents, leading to deficiencies in addressing their specific needs. Resident #11, who has a history of PTSD, was observed reading a book in a wheelchair and did not respond to an interview attempt. Her roommate mentioned that she is hard of hearing and does not wear hearing aids. Despite having a care plan that included PTSD as a diagnosis, the plan lacked specific interventions related to her triggers and preferences for care. Staff members, including a CNA and the Social Services Director, were unaware of the resident's PTSD triggers, and the care plan did not include individualized interventions to address her trauma history. Resident #9, diagnosed with end-stage renal disease and dependent on dialysis, also had an incomplete care plan. The care plan failed to specify the location of the dialysis shunt and the dialysis center details, which are critical for managing potential complications related to hemodialysis. The MDS Coordinator acknowledged missing updates to the care plan, which should have been individualized and updated as needed. The Director of Nursing confirmed that care plans should be individualized and updated to reflect the resident's needs and conditions. The facility's policies and procedures emphasize the importance of comprehensive, person-centered care plans that include measurable objectives and timeframes. However, the care plans for both residents did not meet these standards, as they lacked specific interventions and updates based on the residents' conditions and needs. The interdisciplinary team is responsible for developing and implementing these care plans, but the deficiencies indicate a failure to adhere to the facility's policies and procedures.
Plan Of Correction
1. The care plan for resident #11 was updated to include interventions related to approach and determining her preference for care by MDS director on. Care plan for resident #9 was updated to include information regarding what center the resident goes to for by MDS director on. 2. MDS director or designee will complete quality assurance checks on resident care plans to ensure they include individualized goals and interventions by. 3. Reeducation was provided to the IDT team that resident care plans must be individualized with goals and interventions. 4. Quality assurance checks will be conducted of four random residents' care plans by the MDS director or designee 3 times a week for 6 weeks, then weekly for an additional 6 weeks to ensure they are individualized with interventions and goals. All results of the quality assurance checks/audits will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify specific triggers related to post-traumatic stress disorder (PTSD) and develop an individualized plan of care to prevent re-traumatization for Resident #11. The resident, who has a history of unspecified dementia, major depressive disorder, generalized anxiety, and PTSD, was observed reading a book and did not respond to an interview attempt. Her care plan mentioned the risk of re-traumatization related to childhood trauma but lacked specific interventions tailored to her needs. Interviews with staff revealed a lack of awareness and training regarding PTSD triggers and individualized care approaches. A Certified Nursing Assistant (CNA) was unaware of Resident #11's PTSD diagnosis and could not identify her triggers. The Director of Nursing (DON) acknowledged that staff are educated to look for behaviors but did not know the resident's specific triggers. The Social Services Director (SSD) confirmed that the care plan should include interventions related to approach and preferences for care but had not individualized triggers for PTSD care plans. The facility's policy on Trauma Informed Care emphasized the importance of culturally sensitive and person-centered care, yet staff interviews indicated a gap in training and implementation. The SSD was aware of the resident's trauma history but had not seen psych notes related to physical and sexual abuse. The deficiency highlights a failure to provide trauma-informed care by not adequately identifying and addressing the resident's PTSD triggers in her care plan.
Plan Of Correction
1. The care plan for resident #11 was updated to include specific triggers related to prevent re- to by the MDS director on. 2. MDS director or designee will complete quality assurance checks on resident care plans to ensure they have an individualized plan to prevent re- by. 3. Reeducation was provided to the IDT team that resident care plans must be individualized and include specific triggers related to, to prevent re- by NHA or designee on. 4. Quality assurance checks will be conducted of four random residents care plans by the MDS director or designee 3 times a week for 6 weeks then weekly for an additional 6 weeks to ensure they are individualized with specific triggers related to to prevent re- to. All results of the quality assurance checks/audits will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in two resident rooms, specifically rooms #201 and #214. In room #201, a resident reported that the dark brown armoire's drawer was broken and could not be opened, which had been an issue for some time. The observation confirmed that the top drawer of the armoire was separated from the rest of the drawer on the left side. In room #214, the toilet base was not secured to the floor, and both residents of the room confirmed they used the toilet. Staff D, a Certified Nursing Assistant, mentioned that if staff noticed anything in need of repair, a work order should be placed in the facility's electronic work order system. The Housekeeping Director stated that housekeeping cleans the bathrooms daily and would inform the Maintenance Director of any repairs needed, as housekeeping staff do not have access to the electronic work order system. The Maintenance Director confirmed not having any work orders for the issues in both rooms and acknowledged the need for repairs upon observation. Additionally, the facility failed to provide a policy for Building/Equipment Maintenance when requested. Photographic evidence was obtained to support these findings.
Plan Of Correction
1. The armoires drawer in was repaired on by the maintenance director. The toilet base in was secured to the floor on by the maintenance director. 2. Quality assurance check of all residents armoires and toilets was completed on by maintenance director. No additional findings were noted. 3. Facility staff received education on utilizing the TELS system for work orders by NHA or designee by. 4. Quality assurance checks on armoires and toilets will be completed by IDT members 3x a week for 6 weeks then 1x a week for an additional 6 weeks. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
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