Concordia Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Petersburg, Florida.
- Location
- 321 13th Ave N, Saint Petersburg, Florida 33701
- CMS Provider Number
- 105714
- Inspections on file
- 18
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 6 (3 serious)
Citation history
Health deficiencies cited at Concordia Manor during CMS and state inspections, most recent first.
A resident who was dependent on staff for all care and required two-person assistance for bed mobility fell from bed when only one staff member was present and unaware of the care plan requirements. The resident's pain was not promptly assessed or managed, there were delays in obtaining diagnostic imaging and physician evaluation, and documentation was incomplete. Communication failures and lack of staff training contributed to ongoing pain and distress for the resident following the incident.
A resident who was bedbound and dependent on two-person assistance for care fell from bed while only one staff member was present, leading to a hip fracture and ongoing pain. The staff member was unfamiliar with the resident’s needs, and pain management was inconsistent. There was a lack of timely physician assessment, incomplete documentation, and delayed communication with the family, resulting in a worsened condition for the resident.
Two residents experienced ongoing uncontrolled pain and psychosocial harm after a fall due to the facility's failure to provide timely assessment, notify the physician, complete ordered diagnostics, and consistently administer and document pain management. One resident, who was severely contracted and dependent for all ADLs, was not assisted by two staff as required, leading to a fall and hip fracture. Staff were not adequately trained or informed of care plan changes, and pain care plans were not updated to reflect the resident's increased pain.
A resident with multiple comorbidities and bilateral above-knee amputations, who is dependent on staff for bathing, was not provided showers as preferred due to the facility's lack of bariatric shower equipment. Staff were aware of the resident's wishes but only provided bed baths, and there was no policy or procedure in place to address the need for bariatric accommodations.
The facility did not provide evidence of a current annual diesel fuel quality test for its generator and failed to submit its comprehensive emergency management plan (CEMP) for annual review and approval, as confirmed during record reviews and interviews with the Director of Maintenance.
The facility did not ensure that staff were trained and available on all shifts to manually transfer power to the generator during a power outage, as required by state regulations. The Director of Maintenance was unaware that staff lacked this training, resulting in a deficiency related to emergency environmental control procedures.
A resident in a LTC facility, who was non-verbal and dependent on staff for all care, fell from bed and sustained a head injury due to inadequate staffing. The facility was understaffed, and only one CNA was available to assist the resident, despite the care plan requiring two-person assistance. The incident was not promptly reported or investigated, and the care plan was not active at the time, leaving staff unaware of the resident's needs.
A resident in a LTC facility, who was non-verbal and dependent on staff for all ADLs, fell from bed and sustained a head injury due to insufficient staffing. The CNA, aware of the need for two-person assistance, attempted to care for the resident alone due to understaffing. The facility's administration was slow to respond, and the care plan was not active at the time, contributing to the incident.
The facility failed to timely report allegations of neglect and mistreatment for two residents. One resident's injury was not investigated promptly due to staff being on leave and delayed corporate notification. Another resident reported rough treatment by staff, but the NHA delayed reporting and did not conduct thorough interviews. The facility's process of waiting for corporate approval affected the timeliness of reporting and investigations.
The facility failed to investigate allegations of neglect and mistreatment for two residents. One resident fell from a bed due to inadequate assistance, and the investigation was delayed. Another resident reported rough treatment by staff, but the investigation was incomplete. The facility did not follow its policies, resulting in unresolved allegations.
A facility failed to conduct and document weekly skin assessments for a resident as required by their policy. Over a four-month period, only four skin checks were completed, despite the resident having conditions such as wasting and atrophy. The DON acknowledged the oversight, stating that the assessments should have been documented weekly.
A resident in a LTC facility was left calling for help for 30 minutes without receiving incontinence care, despite multiple staff members passing by. The resident's care plan required assistance with toileting and personal hygiene, but staff failed to respond to her needs, leading to a deficiency in her quality of life.
The facility failed to repair a non-functional air conditioning unit for over a month, despite approval for repairs, and relied on a portable unit in the meantime. Additionally, two resident rooms were not maintained in a safe and sanitary manner, with observed cracking, peeling, and dislodged ceiling material. The NHA confirmed the A/C unit had not been fixed but did not address the room conditions.
The facility did not meet the minimum staffing requirements for nursing and CNAs on five out of twenty-eight days. Nursing care fell below the required 1.0 hours on two days, and CNA care was below the 2.0 hours requirement on three days. The BOM and NHA confirmed the staffing numbers, and the facility's policy holds the administrator and DON responsible for ensuring sufficient staff.
The facility failed to repair a non-functional air conditioning unit for over a month, relying on a portable unit instead. Despite obtaining quotes and approval for repairs, no timeline was provided. Additionally, two resident rooms had issues with cracking and dislodged ceiling material, affecting the safety and sanitation of the environment.
A resident in an LTC facility was left calling for help for approximately 30 minutes without response from staff, despite multiple staff members passing by. The resident needed assistance with toileting and expressed a desire to be clean. The DON confirmed the importance of timely care, and the resident's care plan highlighted her dependency on staff for toileting and a behavior of calling out for help.
The facility failed to provide a safe, clean, comfortable, and homelike environment in six resident rooms and the medication room. Observations included holes in walls, exposed wires, cracked baseboards, and dusty surfaces. The DON and Maintenance Director acknowledged the issues but did not prioritize them due to other safety concerns. The facility's policy on maintaining a safe environment was not effectively implemented.
The facility failed to ensure kitchen equipment was being utilized in safe operating conditions. Observations revealed standing water and constant drips in two refrigerators, and a sink with a makeshift plastic cup to redirect water. Staff interviews confirmed these issues had been ongoing for several months, and maintenance attempts had been ineffective. The Maintenance Director was only present a couple of days a week, and there was a gap in work orders being submitted.
The facility failed to notify a resident and their representative of the bed hold prior to and upon transfer to the hospital. The Bed Hold and In-House Transfer Policy form was incomplete, and interviews confirmed that the facility's practice of notifying the resident or representative at the time of transfer was not followed.
The facility failed to ensure accurate Level I PASRR screenings for seven residents, resulting in discrepancies and incomplete documentation of their mental health diagnoses. The DON acknowledged the inaccuracies and the need for a plan to review and update all PASRRs.
Failure to Ensure Safe Bed Mobility and Timely Medical Response Resulting in Resident Harm
Penalty
Summary
The facility failed to protect residents from neglect by not ensuring safety during bed mobility in accordance with assessed and care planned needs. One resident, who was severely cognitively and physically impaired, dependent on staff for all activities of daily living, and required two-person assistance for bed mobility, sustained a fall from bed during care when only one staff member was present. The staff member was unaware of the resident's two-person assist requirement and did not request help, citing that other staff were busy and that she had not received training specific to the resident. The resident fell while the staff member was preparing to provide care, and the incident was not properly assessed or documented by nursing staff at the time. Following the fall, the resident experienced acute pain that was not promptly addressed. There was a delay in both the assessment and management of the resident's pain, as well as in obtaining necessary diagnostic imaging. The resident was not seen by a physician in a timely manner, and an ordered X-ray was not completed as expected. The resident was eventually transferred to the hospital, where a hip fracture was diagnosed. Upon return to the facility, there were further delays in pain management due to issues with medication orders and communication, resulting in the resident experiencing ongoing pain and distress. Interviews and record reviews revealed inconsistencies and confusion among staff regarding the resident's care plan and required level of assistance. Documentation was lacking for post-fall assessments, pain management, and follow-up care. The resident's family was not promptly notified of the fall, and there were issues with communication and continuity of care between facility staff and the resident's primary care provider. The failure to follow the care plan, provide adequate staffing and training, and ensure timely medical intervention resulted in a worsened condition for the resident and constituted neglect.
Failure to Provide Adequate Staffing and Supervision During Bed Mobility Results in Resident Injury
Penalty
Summary
The facility failed to provide the required number of staff to ensure resident safety during bed mobility, as outlined in the care plans for multiple residents. One resident, who was severely contracted, bedbound, and dependent on two-person assistance for all activities of daily living, experienced a fall from bed while only one staff member was present during care. The staff member assigned was unfamiliar with the resident’s care needs, had not received specific training, and did not request additional assistance due to staffing shortages and being unaware of the resident’s two-person assist requirement. The resident fell to the floor during care, and staff subsequently assisted the resident back to bed without a documented assessment or vital signs being taken at the time of the incident. Following the fall, the resident experienced ongoing and severe pain, which was not consistently addressed or documented by nursing staff. Pain medication was not always administered as ordered, and there were delays in both pain assessment and intervention. The resident’s family was not promptly notified of the fall, and there were issues with communication regarding the resident’s hospital admission, including the use of the wrong name. The resident was eventually transferred to the hospital after continued complaints of pain and was diagnosed with a right hip fracture. The hospital determined the resident was not a candidate for surgery due to contractures and comorbidities, resulting in ongoing physical and psychosocial pain. The facility also failed to ensure timely physician assessment and follow-up after the fall. There was no evidence that the resident was seen by a physician throughout the month following the incident, and an ordered X-ray was not completed in a timely manner. Documentation of post-fall assessments, pain management, and care plan interventions was lacking. Interviews with staff and the resident’s family confirmed that the resident’s pain was not adequately managed, and the care plan interventions were not consistently implemented. These failures resulted in a worsened condition for the resident and created a situation of Immediate Jeopardy.
Failure to Provide Timely and Effective Pain Management Post-Fall
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents following a fall, resulting in ongoing uncontrolled pain and psychosocial harm. One resident, who was severely contracted and dependent on staff for all activities of daily living, sustained a femur fracture after falling from bed during care. Despite clear care plan instructions requiring two-person assistance for bed mobility and transfers, only one staff member was present at the time of the fall. The staff member involved was not adequately trained on the resident's care needs and did not request assistance, citing that other staff were busy. After the fall, the resident was assisted back to bed without a thorough assessment or documentation of vital signs and skin checks, and the family was not promptly notified of the incident. Following the fall, the resident experienced persistent and severe pain that was not effectively managed. There were delays in both the assessment and notification of the physician regarding the resident's pain, and an ordered X-ray was not completed in a timely manner. The resident was eventually transferred to the hospital, where a hip fracture was diagnosed, but she was deemed a poor surgical candidate due to her contractures and comorbidities. Upon return to the facility, there were further delays in administering prescribed pain medication due to prescription issues, and documentation of pain management was inconsistent. Staff interviews confirmed that the resident continued to experience significant pain, especially during care, and that pain assessments and care plan updates were lacking. The facility's documentation and communication failures extended to the care planning process, as the resident's pain care plan was not updated to reflect her increased pain and new interventions were not promptly implemented. Staff were not consistently aware of or following the most current care plan interventions, and there was a lack of coordination between therapy and nursing regarding pain management strategies. The cumulative effect of these failures resulted in ongoing physical pain and psychosocial distress for the resident, and the situation was determined to constitute Immediate Jeopardy.
Failure to Provide Shower Accommodations for Bariatric Resident
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's preference for showers. The resident, who is cognitively intact and dependent on staff for bathing due to multiple comorbidities including multiple sclerosis, morbid obesity, bilateral above-knee amputations, and muscle weakness, repeatedly expressed her desire for regular showers rather than bed baths. Despite her care plan and Kardex specifying scheduled showers twice weekly with assistance, she had not received a shower since admission and was only provided bed baths. Staff interviews confirmed awareness of the resident's preference but cited the lack of appropriate bariatric shower equipment as the reason for not providing showers. Observations of the shower room confirmed the absence of bariatric shower chairs, and staff acknowledged that all available shower chairs were standard size and unsuitable for bariatric residents. The physical therapy assistant indicated she had not been consulted about the need for bariatric equipment, and the regional consultant and nurse consultant were unaware of any policy or procedure for accommodating such needs. Documentation showed the resident had only received bed baths, and there was no evidence of efforts to obtain suitable equipment to meet her preferences.
Failure to Maintain Generator Fuel Quality Testing and Annual Emergency Management Plan Submission
Penalty
Summary
The facility failed to maintain the required annual diesel fuel quality test for its generator, as mandated by NFPA 101, NFPA 99, and NFPA 110. During a record review of the Essential Electrical System (EES) with the Director of Maintenance (DOM), it was found that there was no evidence of a current annual diesel fuel quality test. The DOM confirmed during the interview that the documentation for this test was not available. Additionally, the facility did not submit its comprehensive emergency management plan (CEMP) for annual review and approval as required by Florida Administrative Code 408.821. During a record review with the DOM, it was revealed that the facility could not provide evidence of the CEMP's submission to the county for the required annual review. The CEMP had expired, and the DOM stated that the facility currently has an interim Administrator who has only been at the facility for a few months. No information was provided in the report regarding specific residents or their medical conditions in relation to these deficiencies. The findings were based on documentation review and interviews with facility staff, specifically the DOM.
Plan Of Correction
Fuel sample was collected on by vendor for testing. No residents were affected by deficient practice. Education will be completed with the NHA/designee by regional plant operations on fuel inspection requirements. Audits will be completed by the NHA/designee who will audit the electronic work order system for equipment inspection compliance weekly for four weeks then monthly for two months. Results of the audit will be reported to the QAA&C Committee for comments and recommendations monthly for three months. CEMP was submitted to the county agency for review. No residents were affected by deficient practice. Education was completed with the NHA/designee by the regional director of plant operations regarding the annual requirement for CEMP approval. Audits will be completed by the NHA/designee on the CEMP approval compliance weekly for four weeks then monthly for two months. Results of the audit will be reported to the QAA&C Committee for comments and recommendations monthly for three months.
Failure to Ensure Trained Staff for Manual Power Transfer During Outages
Penalty
Summary
The facility failed to provide a detailed emergency power plan in accordance with the Florida Administrative Code (FAC) requirements. During a record review conducted between 9:15 AM and 10:15 AM with the Director of Maintenance (DOM), it was found that the facility could not provide evidence that an on-site and trained individual was available during all shifts to manually transfer power from the public utility to the generator using the generator's manual transfer switch in the event of a power outage. In an interview conducted concurrently with the record review, the DOM stated that he had only been responsible for the facility for a few months and was not aware that staff were not trained for the task of manually transferring power. This lack of awareness and training among staff directly contributed to the facility's inability to meet the regulatory requirement for emergency environmental control. The deficiency was cited under FAC 59A-4.1265(6)(a), which mandates that nursing homes develop and implement written policies and procedures to ensure effective and immediate activation, operation, and maintenance of the alternate power source. The facility's failure to ensure that staff were trained and available to perform the manual transfer of power during all shifts led to noncompliance with this regulation.
Plan Of Correction
Education was completed with facility staff regarding the manual transfer of power during a power outage through the generator manual transfer switch. New employees will be educated on this process as part of the orientation process. Education will be completed with the NHA/designee by the regional plant consultant on manual transfer of generator task education requirement. An audit will be completed by the NHA/designee and will include all new employee files on transfer of power education completion. The audit will be conducted weekly for 4 weeks, then weekly for 2 weeks, and monthly for 2 weeks. Results of the audit will be reported to the QAA&C Committee for comments and recommendations monthly for three months.
Inadequate Staffing Leads to Resident Injury
Penalty
Summary
The deficiency involved a failure to provide adequate staffing to ensure the safety of a resident during bed mobility, which was consistent with the assessed and care-planned needs. The resident, who was non-verbal and dependent on staff for all care, required the assistance of two staff members for bed mobility. However, on the day of the incident, the facility was understaffed due to call-offs, and only one CNA was available to assist the resident. This resulted in the resident falling from the bed and sustaining a head injury, which required a transfer to a higher level of care. The CNA involved in the incident admitted to attempting to care for the resident alone, despite knowing that the resident required two-person assistance. The CNA stated that she tried to lower the bed and call for help when the resident began to fall, but was unable to prevent the fall. The facility's staffing issues were highlighted by multiple staff members, who reported that understaffing was a common problem and that the administration often allowed shifts to continue without adequate replacements. The facility's policies and procedures for care planning and staffing were not effectively implemented, as evidenced by the unresolved care plan issues and the lack of timely reporting and investigation of the incident. The care plan for the resident was not active at the time of the incident, and staff were not aware of the resident's transfer status. Additionally, the facility's administration failed to promptly report the incident to the appropriate authorities, and the investigation was delayed due to the absence of key personnel.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any of its rights to contest any of these allegations or any allegation or action. #1's care plan was reviewed and updated as indicated. Nursing Home Administrator (NHA) and/or Director of Nursing (DON) conducted an audit of resident grievances and/or incidents to ensure that there were no concerns identified related to insufficient staffing levels. No new concerns were identified. Element #2. A review of facility staffing levels was completed to ensure adequate staffing levels in place to meet the needs of the residents. No additional opportunities identified. An evaluation of current residents was conducted by the Director of Nursing (DON) and/or designee to ensure that no additional residents were by the alleged deficient practice. No other opportunities were identified. Element #3. Current licensed nursing staff were in-serviced on the facility's Policy and Procedure and Neglect, and Policy as it relates to providing necessary assistance with activities of daily living, prevention, and potential for resident harm. Nursing Home Administrator (NHA) and Director of Nursing (DON) were in-serviced by Regional Nurse Consultant and/or Regional Director of Operations Consultant regarding the requirement that a daily staffing meeting/review is completed to ensure that daily minimum staffing levels are met and maintained. A plan was developed and implemented to enhance the hiring of registered, licensed, and certified nursing staff as required to assist with maintaining daily minimum staffing levels. Recruitment efforts continue. Element #4. The Director of Nursing (DON) and/or designee will audit staffing levels three times a week for the next 60 days to ensure that staffing levels are appropriate to meet the needs of the residents. Findings will be brought by the Nursing Home Administrator (NHA) and/or designee to the Quality Assessment and Assurance Committee monthly meeting for three months for further comments and/or recommendations. Element #5. Facility's Allegation of Compliance Date is , 20225.
Neglect Due to Insufficient Staffing Leads to Resident Injury
Penalty
Summary
The deficiency involved a resident who was neglected due to insufficient staffing during a bed mobility task. The resident, who was non-verbal and dependent on staff for all activities of daily living, required the assistance of two staff members for safe bed mobility. However, on the day of the incident, the facility was understaffed, with only one nurse and two CNAs available for the entire building. As a result, a CNA attempted to care for the resident alone, which led to the resident falling from the bed and sustaining a head injury that required hospital transfer. The CNA involved admitted to not asking for help despite knowing the resident required two-person assistance. The CNA attempted to manage the situation by lowering the bed and calling for help, but the resident still fell and was injured. The CNA acknowledged the mistake and attributed it to the lack of available staff, as the facility did not replace staff who called off that day. The incident highlighted a recurring issue of understaffing, which was acknowledged by other staff members who reported similar experiences of being unable to provide adequate care due to insufficient staffing levels. The facility's administration was slow to respond to the incident, with the Director of Nursing and Nursing Home Administrator only becoming aware of the situation days later. The care plan for the resident was not active at the time of the incident, which contributed to the confusion about the required level of assistance. The facility's policies on care planning and injury prevention were not effectively implemented, as evidenced by the unresolved care plan and the lack of timely reporting and investigation of the incident.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any of its rights to contest any of these allegations or any allegation or action. F-600 Free From and Neglect Element #1: Resident #1 was assessed to ensure no further injuries, and that was at a level that was acceptable to the resident. No additional findings noted upon assessment and level at acceptable level for resident. Resident #1's care plan was reviewed and updated as indicated. Nursing Home Administrator (NHA) and/or Director of Nursing (DON) conducted an audit of resident grievances and/or incidents to ensure that there were no concerns identified related to insufficient staffing levels. No new concerns were identified. Element #2: A review of facility staffing levels was completed to ensure adequate staffing levels in place to meet the needs of the residents. No additional opportunities identified. An evaluation of current residents was conducted by the Director of Nursing (DON) and/or designee to ensure that no additional residents were affected by the alleged deficient practice. No other opportunities were identified. Element #3: Current licensed nursing staff were in-serviced on the facility's Policy and Procedure and Neglect, and Policy as it relates to providing necessary assistance with activities of daily living, prevention, and potential for resident harm. Nursing Home Administrator (NHA) and Director of Nursing (DON) were in-serviced by Regional Nurse Consultant and/or Regional Director of Operations Consultant regarding the requirement that a daily staffing meeting/review is completed to ensure that daily minimum staffing levels are met and maintained. A plan was developed and implemented to enhance the hiring of registered, licensed, and certified nursing staff as required to assist with maintaining daily minimum staffing levels. Recruitment efforts continue. Element #4: The Director of Nursing (DON) and/or designee will audit staffing levels three times a week for the next 60 days to ensure that staffing levels are appropriate to meet the needs of the residents. Findings will be brought by the Nursing Home Administrator (NHA) and/or designee to the Quality Assessment and Assurance Committee monthly meeting for three months for further comments and/or recommendations. Element #5: Facility's Allegation of Compliance Date is , 20225.
Delayed Reporting of Allegations of Neglect and Mistreatment
Penalty
Summary
The facility failed to report allegations of neglect and mistreatment in a timely manner for two residents. For the first resident, a hospital visit summary indicated an injury, but the Nursing Home Administrator (NHA) did not initiate an investigation until several days later. The NHA was not informed of the incident over the weekend, and the Director of Nursing (DON) and Director of Rehab were on leave. The NHA only became aware of the incident after being notified by corporate, which delayed the reporting to the Agency for Health Care Administration (AHCA). For the second resident, there were two separate incidents involving allegations of rough treatment by staff. The resident reported a staff member being rough and loud, but the NHA did not report the allegation until a day later. The NHA admitted to not asking detailed questions or interviewing other staff members. In another incident, a family member reported to the state agency that a staff member physically shook and yelled at the resident. The state agency investigated but did not substantiate the claim. The NHA did not obtain statements from the involved staff or follow up on the resident's complaints. The NHA acknowledged that the facility's process of waiting for corporate approval before reporting incidents affected the timeliness of their reporting and investigations. The facility's failure to promptly report and investigate these allegations resulted in deficiencies in meeting the regulatory requirements for reporting alleged violations of neglect and mistreatment.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any of its rights to contest any of these allegations or any allegation or action. F-609, Reporting Alleged Violations Element #1. Resident's #1 and #3 were assessed to ensure there were no negative outcome from the alleged deficient practice. No negative findings identified. Element #2. The Nursing Home Administrator (NHA) and/or designee conducted an audit to identify any other allegations that were reported late within the past 30 days. Residents with previous reports were reassessed for ongoing safety and care concerns. No additional concerns identified. Element #3. Current facility staff will be in-serviced by the Nursing Home Administrator (NHA) and/or designee on timeliness of reporting allegations of neglect, and as well as the timeframes in which to report allegations to ensure they understand when and how to submit allegations in a timely manner. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were in-serviced by the Regional Vice President and/or Regional Nurse Consultant on timeliness of reporting allegations of neglect, and as well as the timeframes in which to report allegations to ensure they understand when and how to submit allegations in a timely manner. Element #4. The Nursing Home Administrator (NHA) and/or designee will audit new reportables once a week for the next 60 days to ensure timeliness of reporting. Findings will be brought by the Nursing Home Administrator (NHA) and/or designee to the Quality Assessment and Assurance Committee monthly meeting for three months for further comments and/or recommendations. Element #5. Facility's Allegation of Compliance Date is .
Failure to Investigate Allegations of Neglect and Mistreatment
Penalty
Summary
The facility failed to thoroughly and timely investigate allegations of neglect and mistreatment for two residents. For the first resident, a Certified Nursing Assistant (CNA) was involved in an incident where the resident fell from the bed. The CNA admitted to not asking for help despite knowing the resident required two-person assistance. The Nursing Home Administrator (NHA) did not initiate an investigation until days later, after being prompted by corporate, and failed to report the incident to the Agency for Health Care Administration (AHCA) in a timely manner. The NHA also did not interview other staff or residents at the time of the incident. For the second resident, there were multiple allegations of rough treatment by staff. The resident reported a CNA for being rough and loud, but the NHA did not thoroughly investigate the claim, failing to ask for detailed statements or interview other staff. Another incident involved a family member reporting to the Department of Children and Families (DCF) that an occupational therapist was physically shaking and yelling at the resident. The NHA did not obtain a statement from the accused staff member or conduct a comprehensive investigation. The facility's policy on prevention and investigation of abuse, neglect, and mistreatment was not followed. The NHA admitted to not obtaining necessary statements or educating staff following these incidents. The facility's failure to adhere to its own policies and procedures resulted in delayed and incomplete investigations, leaving allegations unresolved and unaddressed.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any of its rights to contest any of these allegations or any allegation or action. F-610, Investigate/Prevent/Correct Alleged Violations Element #1. Resident #1 was assessed to ensure no further injuries, and that was at a level that was acceptable to the resident. Resident #1's care plan was updated as indicated. Resident #3 was assessed and her grievance regarding care and customer service was reviewed. The Nursing Home Administrator (NHA) and/or designee reinterviewed staff and residents and collected witness statements. The Nursing Home Administrator (NHA) and/or designee contacted the appropriate reporting agencies, the resident's primary care physician, and resident's families/responsible parties. Element #2. The Nursing Home Administrator (NHA) and/or designee conducted an audit to identify any other grievances pending completion or incomplete investigations occurring within the past 30 days. Opportunities that were identified during the audit were corrected as indicated. An evaluation of current residents was conducted by the Director of Nursing (DON) and/or designee to ensure that no residents were by alleged deficient practices. No opportunities were identified. Element #3. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were in-serviced by the Regional Vice President and/or the Regional Nurse Consultant on the Reportable Investigation, and the timeliness of reporting to state authorities to ensure they understand the process of conducting a complete investigation. Element #4. The Nursing Home Administrator and/or designee will audit new grievances and reportables once a week for the next 60 days for accurate and thorough investigations. Findings will be brought by the Nursing Home Administrator (NHA) and/or designee to the Quality Assessment and Assurance Committee monthly meeting for three months for further comments and/or recommendations. Element #5. Facility's Allegation of Compliance Date is
Failure to Conduct Weekly Skin Assessments
Penalty
Summary
The facility failed to maintain medical records in accordance with professional standards and policy for weekly skin evaluations and assessments for one resident. The facility's policy, titled 'Prevention and Treatment Overview,' mandates weekly skin integrity reviews to proactively identify changes in skin condition. However, a review of the resident's records revealed that only four skin checks were completed over a four-month period, contrary to the policy requirement of weekly documentation. The Director of Nursing (DON) acknowledged the oversight, stating that the skin checks should have been documented weekly but were not. The resident involved was admitted to the facility in 2013 and readmitted with diagnoses including wasting and atrophy, unspecified occlusion, and aphasia. During the period in question, the resident's records showed a knot on the forehead, which was noted in the limited skin assessments conducted. The DON confirmed that the facility missed the required weekly assessments and documentation, which should have been performed as per the facility's policy.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any of its rights to contest any of these allegations or any allegation or action. F-842, Resident Records-Identifiable Information Element #1. Skin check for Resident #1 was completed and documented in the electronic medical record. No new areas of concern were identified. Element #2. Director of Nursing (DON) and/or designee conducted a full-house skin sweep on current residents to identify any new areas of skin. No new areas of concern were identified. Element #3. The Director of Nursing (DON) and/or designee will educate current licensed clinical staff on performing weekly skin checks on active residents and documenting findings in the electronic medical record timely and efficiently. Physicians and families will be notified of any newly identified skin and any new orders will be transcribed into the electronic medical record as indicated. Element #4. Director of Nursing (DON) and/or designee will audit the weekly skin checks for active residents in the electronic medical record every week for eight (8) weeks to ensure that the weekly skin checks are being performed timely. Results of the audits will be brought by the Nursing Home Administrator (NHA) or Director of Nursing (DON) and discussed at monthly Quality Assurance Performance Improvement meetings for review and recommendation for three months. Element #5. Facility's Allegation of Compliance Date is , 20205.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, leading to a deficiency in promoting the resident's quality of life. During a facility tour, the resident was observed calling for help for approximately 30 minutes without receiving assistance. The resident expressed a need for toileting and incontinence care, stating she had soiled herself and wanted to be clean. Despite her continuous calls for help, multiple staff members, including LPNs, CNAs, and other facility personnel, walked past her room without responding to her needs. The resident's care plan indicated she was incontinent of bladder and bowel and required assistance with toileting and personal hygiene. The care plan aimed to establish a resident-specific toileting program to support continence, reduce infection risk, and improve self-esteem. Additionally, the resident had a behavior problem of continuously calling out for help, with interventions to anticipate and meet her needs. However, during the observed period, staff failed to enter the resident's room to address her calls for help, despite the care plan's directives. Interviews with facility staff, including the DON, confirmed the resident's need for timely care, especially given her condition, which included a wound on her sacrum. The DON acknowledged that staff should have responded to the resident's calls for help, regardless of their position within the facility. The report highlights a lack of adherence to the resident's care plan and a failure to provide necessary incontinence care, resulting in a deficiency in the resident's quality of life.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any rights to contest any of these allegations or any allegation or action. F-675 Quality of Life Element #1. Resident #2 was provided with care on in response to her requests, and no adverse outcomes were noted. Care plans for Resident #2 were reviewed and deemed appropriate. Element #2. Director of Nursing (DON) and/or Designee conducted an interview audit to all current residents on to determine if their verbalizations/requests for care were responded to and addressed in a timely manner. No residents were identified. Element #3. Policy regarding Customer Service was reviewed by the Interdisciplinary Team (IDT) and deemed appropriate. Staff A (Licensed Practical Nurse/LPN), Staff B (Certified Nursing Assistant CNA), Maintenance Director, Activities Director, and Staff D (Licensed Practical Nurse/LPN) were individually in-serviced by Director Of Nursing (DON) regarding the expectation that staff respond to and address resident verbalizations/requests to ensure that they are addressed in a timely manner. Element #4. Director of Nursing (DON) and/or Designee will conduct random interview audits with interviewable residents three (3) times a week for four (4) weeks, then two (2) times weekly times eight (8) weeks and/or until substantial compliance is achieved to ensure that resident verbalizations/requests for care are responded to and addressed in a timely manner. Grievances will be completed on behalf of those residents who are verbalizing concerns. Completed audits will be brought to the daily stand-up meetings and reviewed by the Interdisciplinary Team (IDT). Results of the audits will be brought by the Director of Nursing (DON) and discussed at monthly Quality Assurance Performance Improvement Meetings for review and recommendation for three (3) months. Element #6: Facility's Allegation of Compliance Date is
Facility Fails to Repair A/C Unit and Maintain Resident Rooms
Penalty
Summary
The facility failed to ensure timely repairs for one of three air conditioning units, which had been non-functional for approximately one month. The Director of Maintenance (DOM) identified the malfunction on 01/28/2025, and a proposal for repairs was submitted, but as of 03/07/2025, the repairs had not been completed despite approval of the purchase requisition on 02/12/2025. The facility relied on a portable unit in the interim, but no further information was provided regarding the timeline for the repair of the air conditioning unit. Additionally, the facility did not maintain resident rooms in a safe and sanitary manner, as evidenced by observations of cracking, peeling, and dislodged ceiling material with discoloration in two resident rooms. Room 104, which was unoccupied, had three areas of dislodged paint, each approximately 2 feet by 3 feet. Room 105, which housed four residents, had similar issues with cracks and discolored paint material approximately 2 feet by 2 feet. The Nursing Home Administrator (NHA) confirmed the air conditioning unit had not been fixed but did not comment on the condition of the resident rooms.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any rights to contest any of these allegations or any allegation or action. F-0908 Essential Equipment, Safe Operating Condition Element #1. The facility's air conditioning unit was repaired on, Ceiling in resident are scheduled for repair on. Element #2. The facility's remaining air conditioning units were inspected for proper functioning on and no concerns were identified. Resident room ceilings were inspected for cracked and/or peeling paint on No areas of noncompliance were identified. Element #3. Nursing Home Administrator (NHA) and/or Designee in-serviced Concierge personnel and facility staff regarding the identification and reporting of any areas of disrepair or noncompliance of the physical environment in resident rooms. Nursing Home Administrator (NHA) in-serviced Maintenance Director regarding the Physical Environment Policy. Regional Director of Operations Consultant in-serviced the Nursing Home Administrator (NHA) regarding management of product or equipment requisitions. Element #4. Nursing Home Administrator (NHA) will randomly audit resident room ceilings and air conditioning units five (5) times weekly times eight (8) weeks to ensure that ceilings do not have cracked/peeling paint and that air conditioning units are properly functioning. Completed audits will be brought to the stand up meetings and reviewed by the Interdisciplinary Team (IDT). Results of the audits will be brought by the Nursing Home Administrator (NHA) or Director of Nursing (DON) and discussed at monthly Quality Assurance Performance Improvement meetings for review and recommendation. Element #5: Facility's Allegation of Compliance Date is.
Failure to Meet Minimum Staffing Requirements
Penalty
Summary
The facility failed to meet the minimum staffing requirements for nursing and certified nursing assistants (CNAs) on five out of twenty-eight days reviewed. Specifically, the facility did not meet the nursing minimum daily requirement of 1.0 hours of direct care on two days and failed to meet the CNA minimum daily requirement of 2.0 hours of direct care on three days. The daily averages for nursing and CNA care on these days were below the required thresholds, with nursing care averaging as low as 0.8787 hours and CNA care averaging as low as 1.8823 hours per resident per day. Interviews with the Business Office Manager (BOM) and the Nursing Home Administrator (NHA) confirmed the accuracy of the staffing numbers provided on the Long Term Care (LTC) sheets. The BOM stated that the Director of Nursing (DON) is responsible for the staffing schedule, and she inputs the numbers into the payroll system. The NHA acknowledged awareness of the days when staffing numbers did not meet the minimum requirements. The facility's policy and procedure for staffing indicate that the administrator and DON are responsible for ensuring sufficient nursing staff to meet federal and state law requirements, with staffing plans re-evaluated on an ongoing basis.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any rights to contest any of these allegations or any allegation or action. N-063, Minimum Nursing Staff Element #1. A review of the State Minimum Nursing Staff for four (4) weeks (28 days) was conducted on __ of __, and the facility was identified to have failed to achieve minimum staffing requirements for Nursing on __ and __ and for Certified Nursing Assistants (CNA) on __ and __. The facility ensured that appropriate minimum staffing levels were achieved on the dates between those and from __ forward. Element #2. Nursing Home Administrator (NHA) and/or Director of Nursing (DON) conducted an audit on __ of __ resident grievances and/or incidents to ensure that there were no concerns identified which correlated with the day/dates when the facility failed to ensure that minimum staffing requirements were met. No concerns were identified. Element #3. Policy regarding State Minimum Staffing Requirements were reviewed by the Interdisciplinary Team (IDT) and deemed appropriate. Nursing Home Administrator (NHA) and Director of Nursing (DON) were in-serviced by Regional Nurse Consultant and/or Regional Director of Operations Consultant regarding the requirement that a daily staffing meeting/review is completed to ensure that daily minimum staffing levels are met and maintained. A plan is developed and implemented to enhance the hiring of registered and licensed, and certified nursing staff as required to assist with maintaining daily minimum staffing levels. Nurse and CNA's were called for interviews. Waiting for orientation are four (5) CNA's and one (1) Nurse. Other interviews are scheduled and pending. Element #5: Facility's Allegation of Compliance Date is __.
Deficiency in HVAC Maintenance and Room Conditions
Penalty
Summary
The facility failed to ensure timely repairs for one of three air conditioning units, which had been non-functional for about a month. The Director of Maintenance (DOM) acknowledged that the main board of the unit was not working and that a portable unit was being used as a temporary solution. Despite obtaining quotes and submitting them to the corporate office, the repairs had not been approved or completed at the time of the survey. The maintenance log showed a pending service request for the rooftop unit, which had been unresolved for 43 days. Additionally, a purchase requisition for the repair was approved, but no timeline for the repair was provided. The facility also failed to maintain resident rooms in a safe and sanitary manner. Observations revealed that two resident rooms had issues with cracking, peeling, and dislodged ceiling material with discoloration. One room had three areas of concern, each approximately 2 by 3 inches, while another room had cracks with dislodged and discolored painted material approximately 2 by 2 inches. Four residents were residing in the affected room at the time of the survey. The Nursing Home Administrator confirmed the approval of the purchase requisition but did not provide comments on the maintenance and repairs policy.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any rights to contest any of these allegations or any allegation or action. N-112, Physical Environment and Physical Maintenance Element #1. The facility's air conditioning unit was repaired on . Ceiling in resident are scheduled for repair on . Element #2. The facility's remaining air conditioning units were inspected for proper functioning on and no concerns were identified. Resident room ceilings were inspected for cracked and/or peeling paint on . No areas of noncompliance were identified. Element #3. Nursing Home Administrator (NHA) or designee in-serviced Concierge personal and staff regarding the identification and reporting of any areas of disrepair or noncompliance of the physical environment in resident rooms. Nursing Home Administrator (NHA) and/or designee in-serviced Maintenance Director regarding the Physical Environment Policy. Regional Director of Operations Consultant in-serviced Nursing Home Administrator (NHA) regarding management of product or equipment requisitions. Element #4. Nursing Home Administrator (NHA) will randomly audit resident room ceilings and air conditioning units five (5) times weekly times eight (8) weeks to ensure that ceilings do not have cracked/peeling paint and that air conditioning units are properly functioning. Completed audits will be brought to the stand up meetings and reviewed by the Interdisciplinary Team (IDT). Results of the audits will be brought by the Nursing Home Administrator (NHA) or Director of Nursing (DON) and discussed at monthly Quality Assurance Performance Improvement meetings for review and recommendation. Element #5: Facility's Allegation of Compliance Date is .
Failure to Respond to Resident's Calls for Help
Penalty
Summary
The facility failed to provide timely care and services to promote the quality of life for a resident, as evidenced by the resident's continuous calls for help that went unanswered for approximately 30 minutes. During a facility tour, the resident was observed calling for assistance with toileting needs, stating she had 'messed' herself. Despite her cries for help being audible from the hallway, multiple staff members, including an LPN, CNAs, the Maintenance Director, and the Activities Director, walked past the resident's room without responding to her calls. Interviews conducted with the Director of Nursing (DON) and the Clinical Reimbursement Director confirmed that the resident did not use the call bell but would call out for help. The DON stated that staff should enter the room to inquire about the resident's needs when they hear a resident calling for help. The resident expressed a desire to be clean, and the DON acknowledged the importance of timely care, confirming that the resident had experienced a bowel movement during the morning observations. A review of the resident's care plan revealed a focus on providing assistance with toileting and personal hygiene to maintain cleanliness and dignity. The care plan also noted the resident's dependency on staff for toilet use and a behavior problem of continuously calling out for help. The facility did not provide a policy related to this issue, and the deficiency was classified as Class III.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any rights to contest any of these allegations or any allegation or action. N-201, Right to Adequate and Appropriate Healthcare Element #1. Resident #2 was provided with care on in response to her requests, and no adverse outcomes were noted. Care Plans for Resident #2 were reviewed and deemed appropriate. Element #2. Director of Nursing (DON) and/or Designee conducted an interview audit with interviewable residents on /205 to determine if their verbalizations/requests were responded to and addressed in a timely manner. No additional residents were identified. Element #3. Staff A (Licensed Practical Nurse/LPN). Staff B (Certified Nursing Assistant/CNA), Maintenance Director, Activities Director, and Staff D (Licensed Practical Nurse/LPN) were individually in-serviced by Director of Nursing (DON) regarding the expectation that staff respond to and address resident verbalizations/requests in a timely manner. Interdisciplinary staff were in-serviced by the Director of Nursing (DON) and/or Nursing Home Administrator (NHA) regarding the expectation that any staff member can/should respond to resident verbalizations/requests to ensure that they are addressed in a timely manner. Element #4. Director of Nursing (DON) and/or Designee will conduct interview audits with interviewable residents three (3) times weekly for four (4) weeks, then two (2) times weekly times eight (8) weeks and/or until substantial compliance is achieved to ensure that resident verbalizations/requests are responded to and addressed in a timely manner. Grievances will be completed on behalf of those residents verbalizing concerns. Completed audits will be brought to the daily stand up meetings and reviewed by the Interdisciplinary Team (IDT). Results of the audits will be brought by the Director of Nursing (DON) and discussed at monthly Quality Assurance Performance Improvement Meetings for review and recommendation. Element #5: Facility's Allegation of Compliance Date is /20525.
Failure to Maintain a Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in six out of eleven resident rooms and the medication room. During a facility tour, multiple deficiencies were observed, including holes in the walls, exposed wires, cracked and peeling baseboards, dusty and grimy surfaces, and moisture-damaged walls. Additionally, the medication room had dust hanging from the air vent, tangled wires, and a clogged sink. The Director of Nursing (DON) and the Maintenance Director acknowledged these issues but indicated that they were either unaware of them or did not prioritize them due to other safety concerns. The Maintenance Director was responsible for two facilities and was only onsite two days a week, which contributed to the lack of timely maintenance and repairs. The facility's policy on maintaining a safe and homelike environment was not effectively implemented, as evidenced by the numerous unaddressed maintenance issues and the inadequate cleaning of air vents and other surfaces. Staff interviews revealed that the housekeeping staff could not properly clean the air vents due to the design of the dusters, and the maintenance staff only addressed issues when they were brought to their attention. The Nursing Home Administrator and other staff members agreed that the observed conditions did not meet the standards for a homelike environment.
Failure to Maintain Kitchen Equipment in Safe Operating Conditions
Penalty
Summary
The facility failed to ensure kitchen equipment was being utilized in safe operating conditions. Observations revealed that a two-door reach-in refrigerator had standing water at the bottom, with a constant water drip from the top, contaminating a container of strawberries. Another one-door reach-in refrigerator also had standing water at the bottom due to a similar water drip. Additionally, a sink had a plastic cup with the bottom cut out to fit over the faucet, which was used to redirect water squirting upwards back into the sink basin. Staff interviews confirmed that these issues had been ongoing for several months, and maintenance attempts had been ineffective. The Maintenance Director (MD) stated that he was only present at the facility a couple of days a week and worked at a sister facility on other days. The MD mentioned that he had replaced a gasket in the two-door refrigerator and had just replaced the sink faucet on the day of the interview. The facility had a gap in work orders being submitted between August 2023 and March 2024, and the MD noted that work orders were initially communicated by word of mouth. The facility's policy required maintaining equipment in proper working order and reporting malfunctions immediately to the Maintenance Department, which was not adhered to in this case.
Failure to Notify Resident and Representative of Bed Hold
Penalty
Summary
The facility failed to ensure that a resident and their representative received a bed hold notification prior to and upon transfer to the hospital. Specifically, Resident #29 was transferred to the hospital on 03/18/2024, but there was no evidence that the resident or their representative was notified of the bed hold. The Admission Record confirmed the resident's health care decision maker, but the Bed Hold and In-House Transfer Policy form for Resident #29 was incomplete, lacking the representative's name and signature to acknowledge receipt of the notification. Interviews with the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) confirmed that the facility's practice is to notify the resident or representative of the bed hold at the time of transfer. However, this procedure was not followed in the case of Resident #29. The facility's policy requires providing written notice of the bed hold upon admission and an additional notice specifying the duration of the bed hold upon transfer, which was not adhered to in this instance.
Inaccurate and Incomplete PASRR Screenings
Penalty
Summary
The facility failed to ensure accurate Level I Pre-Admission Screening & Resident Review (PASRR) for seven residents. Resident #3 and Resident #26 had discrepancies in their PASRRs, as their current diagnoses of Anxiety Disorder and Major Depression were not reflected. The Director of Nursing (DON) acknowledged the discrepancies during an interview, admitting that the PASRRs did not accurately reflect the residents' mental health conditions. Resident #13 and Resident #20 also had inaccuracies in their PASRRs. Resident #13's PASRR did not indicate a diagnosis of schizophrenia, and Resident #20's PASRR did not reflect the need for a Level II PASRR evaluation despite having multiple mental health diagnoses. The DON admitted to not being fully aware of all the indications for Level II PASRR screening. Additionally, Resident #5, Resident #19, and Resident #18 had incomplete PASRRs. Resident #5's PASRR did not check the qualifying diagnosis of major depressive disorder. Resident #19's PASRR missed the diagnoses of anxiety disorder and epilepsy. Resident #18's PASRR did not include Alzheimer's disease, unspecified dementia, psychotic disturbance, and anxiety, and a Level II PASRR was not submitted. The DON and a Regional Nurse Consultant confirmed the incompleteness of these PASRRs and acknowledged the need for a plan to review and update all PASRRs accordingly.
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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