Douglas Jacobson State Veterans Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Port Charlotte, Florida.
- Location
- 21281 Grayton Terrace, Port Charlotte, Florida 33954
- CMS Provider Number
- 106059
- Inspections on file
- 21
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Douglas Jacobson State Veterans Nursing Home during CMS and state inspections, most recent first.
A resident with Parkinson's and Alzheimer's, who was alert and oriented, was denied access and assistance to a bathroom in the therapy department, resulting in an incontinence episode and a missed medical appointment. Therapy staff did not provide direct toileting assistance or seek help from nursing, instead blocking the bathroom door and insisting the resident return to his unit. The resident reported feeling angry and embarrassed by the incident.
Two residents received controlled substances with documentation showing more doses administered than prescribed, and medication logs were found to be illegible and inconsistent. An LPN was associated with multiple discrepancies, including altered dates and unclear signatures, leading to inaccurate records of medication administration.
A resident with intact cognition and overactive bladder reported that call lights were ignored and care was not provided during the night shift, resulting in the resident being found in the morning with a full urinal, wet bed, and soiled brief. Staff interviews revealed inconsistent accounts of care, and documentation was lacking to confirm that care was provided or refused. The facility's investigation verified the neglect allegation due to insufficient evidence to disprove the resident's claim.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident did not receive timely toileting assistance during the night shift, resulting in being found wet and soiled in the morning, with no documentation of care or refusals. Additionally, two residents experienced discrepancies in the administration and documentation of controlled substances, with records showing more doses given than prescribed and illegible, altered logs. Staff interviews confirmed these failures, and one LPN was linked to multiple documentation issues.
Two residents receiving scheduled Oxycodone-based pain medications experienced discrepancies in the administration and documentation of their controlled substances. The medication logs showed more doses signed out than prescribed, with illegible and altered entries, and dates out of order. An LPN was associated with these documentation errors, admitting to changing dates and being unable to account for multiple signatures, resulting in a failure to protect residents from misappropriation of their property.
A resident with dementia, Parkinson's disease, and overactive bladder was found with a full urinal and wet bedding after reporting that call lights were not answered during the night. Staff interviews provided conflicting accounts, and there was no documentation of incontinence care or refusals for the shift in question or for several other days. The lack of records prevented verification that care was provided, leading to a substantiated finding of neglect.
A resident with Parkinson's and dementia was reportedly bruised during an incident where staff attempted to clean him after he smeared feces on his bed. The resident became combative, and staff held his hands and wrists to prevent him from falling and to protect themselves. The resident's family reported concerns about bruising, and the resident confirmed staff had grabbed him, although he did not feel it was intentional harm. The facility's investigation did not verify abuse, but the Risk Manager noted staff should not have forcibly removed the resident from the bed.
A facility failed to protect residents from neglect by not following hot liquid safety procedures, leading to burns for two residents. One resident spilled hot coffee, causing redness, while another with severe cognitive impairment suffered a second-degree burn from hot chocolate. An LPN reheated the drink without checking its temperature, violating policy. No audits ensured staff compliance, resulting in injuries.
A resident with cognitive impairments suffered a second-degree burn after a staff member reheated hot chocolate without checking the temperature, contrary to facility policy. The resident accidentally spilled the hot beverage, resulting in an avoidable injury. The staff member had been trained on safe serving practices but failed to adhere to them.
A resident with a complex medical history fell and sustained a head injury, leading to a significant drop in blood pressure. The LPN failed to notify the physician of the change in condition or perform a complete neurological assessment, resulting in the resident being found with no vital signs. The medical director stated that he would have sent the resident to the ER if informed of the mental status change.
A resident with Parkinson's disease and dementia, identified as high risk for falls, experienced multiple falls due to inadequate supervision in an LTC facility. Despite a care plan requiring assistance, the resident was often left unsupervised, leading to injuries. The facility failed to update the care plan with new interventions after each fall, as acknowledged by the DON.
A resident with Parkinson's disease and dementia, identified as a high fall risk, experienced 18 falls without adequate updates to their care plan. Despite multiple falls, the facility only added new interventions twice. The DON noted the resident's cognitive limitations and the challenge of implementing effective interventions without compromising independence.
The facility failed to provide an ongoing activity program to meet the interests and support the well-being of its residents. A resident with dementia and Parkinson's was observed restless and disengaged from activities. Another resident with Alzheimer's was found sleeping or passively sitting without structured activities. A third resident with severe cognitive and sensory impairments was not engaged in meaningful activities. Staff shortages and lack of qualified personnel contributed to the deficiency.
The facility failed to have a qualified Activity Director, impacting the activities program. Staff lacked necessary credentials, and the absence of a qualified director since early August led to limited activities, especially for residents in secured units. An interim director was present for a week, but the deficiency affected all residents' well-being.
A resident with multiple medical conditions experienced a fall with a head injury. The LPN failed to complete necessary neuro checks, noting the resident was asleep and did not want to wake him, despite a significant drop in blood pressure. The facility lacked a policy for neuro checks, and the resident was later found with no vital signs.
The facility failed to provide two residents with the required Skilled Nursing Advanced Beneficiary of Non-Coverage form (CMS-10123) in a timely manner, as per policy. The notice, which should be given at least two days before the end of a Medicare-covered Part A stay, was not documented as provided within the required timeframe. Staff K, the social worker program manager, admitted to sending notices via regular mail without documentation of the timing, leading to the deficiency.
Resident Denied Restroom Access and Assistance in Therapy Department
Penalty
Summary
A deficiency occurred when a resident was denied access and assistance to a bathroom in the therapy department, resulting in an incontinence episode. The incident took place when the resident, who was on his way to a doctor's appointment, urgently needed to use the restroom and attempted to use the therapy department bathroom. Staff in the therapy department informed the resident that he could not use the restroom without assistance and that he was not permitted to use the therapy bathroom unless he was in treatment. The staff offered to take the resident back to his unit to use the bathroom, but did not offer direct assistance with toileting in the therapy department. Additionally, a wheelchair was placed in front of the bathroom door to block access, and no staff contacted the nursing department for assistance. The resident, who had diagnoses of Parkinson's disease and Alzheimer's disease, was alert and oriented with intact cognition, as indicated by a recent assessment. He required assistance for transfers (stand and pivot) and sometimes used a sit-to-stand lift, but therapy notes indicated he was able to use the restroom with minimal to no assistance. Despite his ability to communicate his needs and his history of being able to toilet himself, the staff did not provide the necessary support or allow him to use the available restroom, leading to the resident soiling himself and missing his scheduled appointment. Staff statements confirmed that the resident expressed urgency and distress, and that the therapy staff did not personally assist him to the restroom nor did they seek help from nursing staff. The Director of Rehab later stated that the facility's verbal policy is to accommodate all residents' restroom needs and that there was no excuse for denying access. The resident reported feeling angry and embarrassed by the incident, which he described as inconsistent with his prior experiences at the facility.
Failure to Prevent Misappropriation and Inaccurate Documentation of Controlled Substances
Penalty
Summary
The facility failed to protect residents' rights to be free from misappropriation of property by not maintaining effective processes to prevent the misappropriation of controlled substances for two residents. For one resident, a physician's order specified a controlled substance to be administered four times daily, but pharmacy records and controlled substance logs revealed that the medication was being signed out and documented as administered more frequently than prescribed, with some days showing up to 11 doses. The controlled substance logs were found to have multiple dates scribbled over or written illegibly, making it difficult to determine the actual administration times and dates. Despite the discrepancies, the physical count of medication matched the expected amount, but the documentation did not align with the prescribed administration schedule. A similar issue was identified for another resident, where the controlled substance record of use also showed illegible and out-of-order dates, and the number of tablets signed out did not match the administration history. The logs indicated that more tablets were being signed out than were actually administered according to the administration history, and the documentation was inconsistent and unclear. The facility's investigation found that these discrepancies were associated with a specific LPN, who admitted to changing dates on medication documents and could not account for multiple signatures or events on the medication cart. The LPN denied taking any pills or overmedicating residents but acknowledged making documentation errors. The deficiencies were discovered when the pharmacy consultant identified that a refill request for a controlled substance was made earlier than expected, prompting an audit of the controlled substance records. The audit revealed that the documentation did not accurately reflect the administration of medication as ordered by the physician, and the logs were not maintained in a legible or orderly manner. The facility's own investigation confirmed the documentation issues and linked them to the actions of the LPN involved.
Failure to Prevent Resident Neglect Due to Lack of Night Shift Care and Documentation
Penalty
Summary
A deficiency occurred when a resident's right to be free from neglect was not upheld, as the facility failed to ensure the resident received necessary care during the night shift. The resident, who had diagnoses including overactive bladder and required partial assistance for mobility and toileting, reported that he called for help throughout the night but did not receive assistance. Upon morning shift change, staff found the resident with a full urinal, wet bed, and soiled brief, confirming that his care needs had not been met during the previous shift. Interviews with staff revealed inconsistencies in the accounts of care provided. Some CNAs and nurses stated that the resident was checked and attended to multiple times during the night, while others acknowledged that it was not uncommon to find residents with overflowing urinals and soaked beds at the start of the morning shift. The resident himself reported frequent issues with the night shift not responding to call lights, and described an incident where a nurse entered his room, turned off the call light, and left without providing care, despite his bed being soaked. A review of the clinical record and facility documentation showed a lack of evidence that care was provided or that the resident refused care during the night in question. The facility's own investigation verified the allegation of neglect, noting that there was insufficient documentation to disprove the resident's claim. The Director of Nursing confirmed the absence of documentation for care provided to the resident on multiple shifts, and staff interviews indicated that there was no clear policy for documenting such care.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent Neglect and Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to protect residents' rights to be free from neglect and misappropriation of property, as evidenced by two main deficiencies. One resident, who was care planned for overactive bladder and required a two-person assist for transfers and toileting, reported that he called for help throughout the night but did not receive assistance. Multiple staff interviews and the facility's own investigation confirmed that the resident was found in the morning with a full urinal, wet bed, and wet brief, and that there was no documentation of care provided or refusals during the night shift. Staff acknowledged that it was not uncommon to find residents wet and call lights on at shift change, and the Director of Nursing confirmed a lack of documentation for care provided on multiple shifts. Additionally, the facility failed to have effective processes in place to prevent the misappropriation of controlled substances for two residents. Pharmacy records and controlled substance logs revealed that one resident received more doses of a controlled medication than prescribed, with documentation showing up to 11 doses in a single day when only four were ordered. The logs were found to be illegible, with dates scribbled over and not in order, and similar discrepancies were found for another resident's controlled medication. The pharmacy consultant and facility staff confirmed that the counts were correct, but the administration records were inaccurate and not properly reconciled. Interviews with staff, including the DON, Risk Manager, and LPNs, revealed that one LPN was associated with multiple documentation discrepancies, including altered dates and signatures she could not recall. The facility's investigation verified these issues, and the LPN denied taking any pills or overmedicating residents. The lack of accurate documentation and oversight led to the inability to ensure that residents received medications as ordered and that their property was safeguarded.
Failure to Prevent Misappropriation and Inaccurate Documentation of Controlled Substances
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property by not maintaining effective processes to prevent the misappropriation of controlled substances. Specifically, for two residents with physician orders for scheduled doses of Oxycodone-based pain medications, discrepancies were found in the administration and documentation of these controlled substances. The controlled substance logs showed that more doses were signed out than prescribed, with some days reflecting up to 11 doses when only 4 were ordered. Additionally, the logs contained multiple instances of dates being scribbled out, written over, or entered out of order, making it difficult or impossible to accurately track medication administration. For one resident, pharmacy records indicated that 120 tablets of Oxycodone-APAP were delivered as a 30-day supply, but the medication was requested for refill eight days early. Upon review, it was found that the administration history did not match the expected dosing schedule, and the controlled substance logs were inconsistent and illegible in places. The count of tablets in the blister packs matched the documented end count, but the daily administration records showed more doses than prescribed, and missed doses were also documented. Similar issues were identified for another resident receiving Oxycodone, with the controlled substance logs again showing illegible entries and dates out of sequence. The facility's investigation revealed that these discrepancies were associated with an LPN, who admitted to changing dates on medication documents and could not account for multiple signatures. The LPN denied taking any pills or overmedicating residents but acknowledged making documentation errors. The facility identified that the issues were not isolated to a single resident but affected multiple residents receiving controlled substances, and the documentation practices failed to ensure accurate and legible records of controlled substance administration.
Failure to Provide and Document Incontinence Care Resulting in Resident Neglect
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's right to be free from neglect by not ensuring that incontinence care was provided according to the resident's needs. The resident, who had diagnoses including dementia, Parkinson's disease, and overactive bladder, was assessed as frequently incontinent and required partial to moderate assistance for toileting and hygiene. Despite being care planned for urinary incontinence and having urinals at the bedside, the resident reported that call lights were used throughout the night without response, resulting in a full urinal and wet bed and clothing in the morning. Multiple staff interviews confirmed that the resident was found in this condition at shift change, and the resident expressed dissatisfaction with the care received during the night shift. The facility's investigation into the incident revealed conflicting staff accounts regarding the care provided during the night in question. While some staff stated that the resident was attended to multiple times, there was no documentation in the clinical record to support that incontinence care was provided or that the resident refused care during the relevant shift. The lack of documentation extended to several other days and shifts, as verified by the Director of Nursing, indicating a broader issue with record-keeping for incontinence care and resident refusals. The facility's policies required identification and intervention in situations where neglect could occur, but the absence of documentation made it impossible to verify that the resident's needs were met. The investigation ultimately verified the allegation of neglect due to the inability to disprove the resident's claim and the lack of evidence showing that appropriate care was provided during the night shift.
Resident's Right to Be Free from Physical Abuse Not Protected
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse. The incident involved a male resident with a history of Parkinson's disease, dementia, bipolar disorder, major depressive disorder, and obsessive-compulsive disorder. On the night of the incident, the resident was reportedly smearing feces on his bed and became combative when staff attempted to clean him. The staff, consisting of an LPN and a CNA, held the resident by his hands and wrists to prevent him from falling out of bed and to protect themselves from being hit by the resident, who was using a reaching tool as a weapon. The resident's family reported concerns about bruising on the resident's hands and wrists, which they believed resulted from staff forcibly removing him from the bed. The resident confirmed to the Risk Manager that staff had grabbed his hands and wrists, causing bruising, although he did not feel the staff intentionally tried to hurt him. The Risk Manager observed the bruising and noted the resident's mental anguish following the incident, indicating psychological support was being provided. The facility's investigation concluded that the allegation of abuse was not verified, citing the resident's combative behavior and the staff's actions to ensure his safety. However, the Risk Manager acknowledged that staff should not have removed the resident from the bed against his will and did not fully document or investigate the family's claim about prying the resident's fingers from the handrail. The report highlights a deficiency in the facility's handling of the situation, particularly in protecting the resident from potential abuse and adequately investigating the incident.
Failure to Adhere to Hot Liquid Safety Procedures Results in Resident Burns
Penalty
Summary
The facility failed to protect residents from neglect by not adhering to its hot liquid safety procedures, resulting in thermal burns to two residents. The facility's policy required that hot beverages be served at a safe temperature to prevent scalding and burns, with temperatures recorded daily. However, an incident occurred where a resident spilled hot coffee on himself, resulting in redness to his abdomen and upper thigh. This incident highlighted the facility's failure to ensure staff followed the hot liquid safety procedures. Another incident involved a resident with Alzheimer's disease and severe cognitive impairment, who sustained a partial thickness thermal burn after hot chocolate spilled onto his lap. The resident's cognitive skills were severely impaired, requiring setup and cleanup assistance at meals. Despite this, the hot chocolate was served at an unsafe temperature, leading to a burn that evolved from a first-degree to a second-degree burn. The resident reported that the hot chocolate was very hot and spilled from the table onto his lap. The facility's investigation revealed that an LPN reheated the hot chocolate without rechecking its temperature, contrary to the facility's policy. The LPN had previously signed an in-service form acknowledging the requirement to check temperatures before serving. The facility confirmed that no audits were conducted to ensure staff compliance with the hot liquid safety procedures, resulting in the resident's injury.
Failure to Ensure Safe Serving of Hot Beverages
Penalty
Summary
The facility failed to ensure the safe serving of hot beverages, resulting in an avoidable thermal burn for a resident. On the specified date, a staff member reheated a cup of hot chocolate for a resident without verifying that the beverage was at a safe temperature. The resident, who had severe cognitive impairments and required assistance during meals, accidentally spilled the hot chocolate on his lap, leading to a second-degree burn on his left anterior thigh. The facility's policy on hot liquid safety was not followed, as the temperature of the beverage was not checked after reheating, and the resident was not adequately supervised. The resident involved was an elderly male with Alzheimer's disease, dementia, and other health conditions, which impaired his cognitive skills and decision-making abilities. The incident occurred when the resident was in his wheelchair, and the hot chocolate was placed on a bedside table. Despite the resident's preference for cooler beverages, the staff member reheated the drink and added ice chips without ensuring the temperature was safe. The resident reported that he did not request the reheating and that the cup tipped over from the table, causing the burn. The facility's incident investigation revealed that the staff member involved had previously received training on serving hot liquids safely, including checking temperatures before serving. However, the staff member did not adhere to these guidelines, as the temperature was not checked after reheating the beverage. The Director of Nursing and the Risk Manager confirmed that the staff member did not follow the facility's policy, leading to the resident's injury.
Failure to Notify Physician of Change in Condition After Resident Fall
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident who experienced a fall resulting in a head injury. The resident, an elderly male with a complex medical history including Type 2 Diabetes, Dementia, and a cardiac pacemaker, fell and sustained a head injury. Following the fall, the resident complained of a headache and was observed with a reddened spot on his head. Despite these signs, the facility did not adequately monitor or document the resident's neurological status, as evidenced by missing documentation of pupil reaction and hand grasp. The resident's blood pressure showed a significant drop from 152/80 to 100/50, which was not recognized as concerning by the LPN on duty. The LPN did not notify the physician of this change, nor did she perform a complete neurological assessment, citing the resident's sleep as a reason. The resident was later found with no vital signs, and the medical director indicated that had he been informed of the change in mental status, he would have recommended sending the resident to the emergency room.
Inadequate Supervision Leads to Multiple Falls for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent avoidable fall-related accidents for a resident identified as being at high risk for falls. The resident, who had a history of falls and a hip fracture, was diagnosed with Parkinson's disease, dementia, and other mobility issues. Despite being assessed as requiring assistance for transfers, ambulation, and toileting, the resident experienced multiple falls, both witnessed and unwitnessed, over several months. Observations revealed that the resident was often left unsupervised, contrary to the care plan interventions, which included keeping personal items and call lights within reach and using anti-roll backs on the wheelchair. The facility's fall risk assessments consistently indicated a high risk for falls, yet the care plan was not updated with new interventions following each fall. The Director of Nursing acknowledged the lack of documentation for new interventions after falls, except for a few instances. The resident sustained injuries, including skin tears and a rib fracture, following falls. Despite the facility's fall program encouraging frequent rounding, the resident was often found alone in various locations without supervision. The DON expressed uncertainty about further interventions, citing the resident's cognitive limitations and the desire to maintain the resident's independence.
Failure to Update Care Plan for High Fall Risk Resident
Penalty
Summary
The facility failed to review and revise the comprehensive person-centered care plan for a resident based on ongoing clinical assessments and identified risks for falls. The resident, who was admitted with diagnoses including Parkinson's disease, dementia, and mobility issues, was identified as a high fall risk. Despite this, the care plan was not updated with new interventions following multiple falls, except on two occasions. The resident experienced 18 falls, both witnessed and unwitnessed, over a period of time, with some resulting in injuries such as skin tears. The Director of Nursing (DON) acknowledged the lack of documentation for new interventions after each fall, except for the addition of nonskid footwear and a protective bumper on specific dates. The DON expressed uncertainty about further interventions due to the resident's cognitive limitations, suggesting that one-on-one supervision might be necessary but was not implemented to maintain the resident's independence. The facility's fall program included purposeful rounding, but it was not sufficient to prevent the resident's repeated falls.
Deficiency in Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing activity program tailored to meet the interests and support the physical, mental, and psychosocial well-being of its residents. This deficiency was observed in three residents who were not engaged in meaningful activities. Resident #109, diagnosed with dementia, Parkinson's disease, and other conditions, was frequently observed sitting in front of a TV without awareness or interest in the program. Despite the presence of an activity calendar, the resident was not involved in any activities and required frequent redirection for safety due to restlessness and attempts to climb out of the wheelchair. Resident #31, with diagnoses including dementia and Alzheimer's disease, was observed sleeping or sitting passively without engagement in scheduled activities. Although music was played, there was no structured activity, and the resident did not respond to attempts at interaction. Staff confirmed that no activity personnel were present on the unit during certain shifts, and activities were limited to passive entertainment like music or TV. Resident #62, with severe cognitive impairment and sensory losses, was also observed sitting in front of a TV without engagement. Staff acknowledged the lack of individualized activities for residents with vision and hearing impairments and confirmed that activities were not consistently provided due to staffing shortages. The facility had not had a qualified Activity Director since early August, and the current staff lacked the necessary credentials in therapeutic recreational activities, further contributing to the deficiency.
Lack of Qualified Activity Director in Facility
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by regulations. The position description for the Activity Director outlined responsibilities including the development, implementation, supervision, and evaluation of activity programs tailored to meet the interests and well-being of each resident. However, interviews with staff revealed that the current activity staff lacked the necessary credentials in therapeutic recreational activities. Activity Staff A confirmed she did not possess the required qualifications, and Activity Supervisor Staff G admitted that no one in the department held the necessary credentials. The facility had been without a qualified Activity Director since early August, and the absence of qualified personnel affected the ability to conduct activities, particularly for residents in secured units. The Administrator acknowledged the deficiency, stating that the facility was actively seeking to hire a qualified Activity Director. Although a regional interim Activity Director was present for a week to oversee the program, this was not a permanent solution. The lack of qualified staff led to limited activity offerings, with staff unable to adhere to the activity calendar or provide individualized activities for residents with specific needs, such as those with vision and hearing impairments. The deficiency had the potential to impact all residents in the facility, as the activities program is integral to their physical, mental, and psychosocial well-being.
Failure to Conduct Proper Neurological Checks After Resident Fall
Penalty
Summary
The facility failed to ensure that nursing staff were competent in conducting neurological checks for a resident who experienced a fall with a head injury. The resident, a male with a history of multiple medical conditions including Type 2 Diabetes, Dementia, and Hypertension, was admitted on palliative care. After a fall, the resident complained of a headache and had a noticeable reddened spot on his head. Initial neuro checks showed a blood pressure of 161/96, which later dropped significantly to 100/50. However, the Licensed Practical Nurse (LPN) did not complete the neuro checks, as she documented the resident as asleep and did not want to wake him, failing to check pupil reaction and hand grasp. The LPN did not recognize the drop in blood pressure as significant and did not take further action. The resident was later found with no vital signs. The facility did not have a policy for completing neuro checks, and the Director of Nursing confirmed that neuro checks were not completed as required. The Director also stated that residents with head injuries should be awakened to complete neuro checks, which was not done in this case.
Failure to Provide Timely Notice of Non-Coverage
Penalty
Summary
The facility failed to provide two residents with the required Skilled Nursing Advanced Beneficiary of Non-Coverage form (CMS-10123) to inform them of potential liability for payment and their right to appeal. According to the facility's policy, this notice should be given at least two days before the end of a Medicare-covered Part A stay or when all Part B therapies are ending. However, for Resident #48, the last covered day of Part A service was on 2/29/24, but the durable power of attorney signed the form on 3/13/24. Similarly, for Resident #220, the last covered day was on 05/15/24, and the form was signed on 5/20/24. There was no documentation indicating that either resident received the notice prior to the end of their services. During an interview, Staff K, the social worker program manager, admitted that the process involved giving notice via regular mail, not certified mail, and there was no documentation of when the notice was sent. Staff K also mentioned that notice was provided verbally, but again, there was no documentation to confirm that this was done within the required timeframe of two days prior to the end of service. This lack of documentation and adherence to the facility's policy resulted in the deficiency noted in the report.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
