Eagle Lake Nursing And Rehab Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Petersburg, Florida.
- Location
- 1100 66th St N, Saint Petersburg, Florida 33710
- CMS Provider Number
- 105292
- Inspections on file
- 22
- Latest survey
- September 18, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Eagle Lake Nursing And Rehab Care Center during CMS and state inspections, most recent first.
A resident with multiple diagnoses was transferred to a hospital due to disruptive behavior and suicidal ideation. The LTC facility failed to document the reasons for not readmitting the resident, despite policy requirements. Interviews revealed a lack of discharge planning and inadequate documentation of the resident's condition and needs.
A resident with multiple diagnoses, including bipolar disorder and anxiety, was not permitted to return to the LTC facility after hospitalization for aggressive and suicidal behavior. Despite the facility's policy that emergency transfers are not discharges, the resident was denied readmission due to safety concerns. The facility failed to document evaluations or develop a discharge plan, leading to a deficiency in transfer and discharge rights.
A facility failed to provide a written transfer and discharge notice to a resident's representative and the LTC Ombudsman. The resident, with multiple diagnoses, was transferred to a hospital due to safety concerns, but the family was only informed by phone. Facility staff confirmed no discharge plan was in place, and the required notice was not provided.
A resident experienced significant medication errors at an LTC facility, where incorrect dosages of Suboxone and vancomycin were administered. The resident, admitted for antibiotic treatment and opioid withdrawal management, was given only 2 mg of buprenorphine instead of the prescribed 8-2 mg Suboxone, leading to severe withdrawal symptoms and multiple hospital readmissions. Additionally, vancomycin was not administered as per hospital discharge instructions, further compromising the resident's health.
The facility failed to maintain an infection prevention program for six months, with no staff trained in infection control. The DON lacked formal training, and the last infection control documentation was from October 2022. Outdated policies were not reviewed, and hand hygiene was neglected during meal service. Enhanced barrier precautions were absent for two residents with IV lines, and staff were unaware of these precautions.
The facility lacked a qualified Infection Preventionist, as the DON, who assumed her role recently, had no formal training or certification in infection control. The NHA confirmed no staff had completed infection prevention training, and the DON struggled with gathering infection control documentation, with the last records dating back to October 2022.
The facility failed to maintain a clean and homelike environment, with observations of holes in walls, chipped paint, rusted grab bars, and broken blinds. The Maintenance Director admitted to not conducting room audits and cited a lack of time and resources for repairs. Facility policies on cleanliness and maintenance were not effectively implemented, resulting in an unsafe and uncomfortable environment for residents.
The facility failed to complete accurate Level I PASRRs for several residents with mental disorders, including those admitted during the COVID-19 waiver period. The deficiency involved incomplete or missing PASRRs for residents with psychiatric diagnoses such as depression and schizophrenia. The Nursing Home Administrator acknowledged the oversight, citing a lack of an Admissions Director and misunderstanding of post-waiver requirements.
The facility failed to complete and transmit MDS assessments for two residents within the required timeframe. The assessments, due on a specific date, were delayed and finalized over a month later. Staff acknowledged the oversight and confirmed the assessments were not completed within the expected 14-day period.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS inaccurately indicated the presence of a catheter, which had been removed shortly after admission. Another resident's MDS incorrectly marked bed rails as not used, despite the resident's reliance on them for mobility and balance. These inaccuracies highlight discrepancies between documented care needs and actual conditions.
The facility failed to implement effective care plans for two residents. One resident with cognitive impairment was found with his bed in a high position against his care plan, while another resident with a staph infection was observed smoking unsupervised without a complete smoking care plan. Staff were unaware of these care plan requirements, indicating communication gaps.
A resident with multiple medical conditions was not provided adequate assistance with personal hygiene, resulting in overgrown facial hair and nails. Despite the resident's preference for being clean-shaven and having trimmed nails, staff failed to meet these needs due to poor documentation and resource issues. Observations and staff interviews highlighted inconsistencies in care delivery and documentation practices.
The facility failed to adhere to physician's orders for oxygen therapy for a resident with COPD, administering 3.5 LPM instead of the prescribed levels. Additionally, another resident using oxygen therapy was found with petroleum jelly, a flammable product, in their room, contrary to safety policies. Staff interviews revealed a lack of awareness and training on oxygen safety protocols.
A facility was found to have a 48% medication error rate during a survey. An LPN administered incorrect dosages and missed medications for two residents. The LPN was unaware of some errors and expressed being behind schedule. The DON acknowledged issues with medication administration timeliness and challenges with the EMAR system. The facility's policy requires timely and accurate medication administration, which was not consistently met.
A resident reported that their bed rail was loose and unsafe, despite notifying the NHA and maintenance multiple times. The Maintenance Director had signed off on audits indicating checks were done, but no work orders were completed for the resident's bed rails. The facility's policy requires regular inspection and immediate repair of malfunctioning equipment.
A resident's call light system was malfunctioning, causing delays in assistance as the light activated in a neighboring room. The facility had installed a new system earlier in the year, but improper installation led to crossed wiring. Staff were aware and instructed to check both rooms when the light was activated. The Maintenance Director and Nursing Home Administrator acknowledged the issue, but the facility lacked a call light policy.
The facility failed to maintain an effective pest control program, resulting in flying insects in resident areas over several days. Observations showed a resident frequently surrounded by insects, affecting his daily activities, while another resident reported flies disturbing her sleep and meals. The pest control log indicated ongoing issues with flying insects, but recent pest control efforts focused only on rodents, neglecting the insect problem.
The facility failed to assess and plan for two residents to self-administer medications. One resident was found with nasal spray brought by family, and another was observed self-administering eye drops without evaluation or care plan intervention. The facility's policy requires an interdisciplinary team assessment and physician's order for self-medication, which was not followed.
Failure to Document Transfer and Discharge Reasons
Penalty
Summary
The facility failed to document adequately the reasons for not meeting the needs and readmitting a resident who was transferred and discharged. The resident, who had multiple diagnoses including multiple sclerosis, bipolar disorder, and anxiety, was initially admitted in June 2023. Despite being stable and cooperative according to a psychiatric note, the resident exhibited disruptive behavior, leading to an emergency discharge to the hospital. The facility did not document the course of events or the rationale for not allowing the resident to return. The resident was involved in incidents that included attempting to exit the building and expressing suicidal ideation, which led to involuntary examinations and hospitalizations. The facility's documentation did not reflect these events accurately, and the resident's medical record lacked clear documentation of the transfer and discharge process. The facility's policy required documentation of efforts to ascertain the resident's condition and needs, which was not fulfilled. Interviews with facility staff revealed that the resident was considered a long-term care resident with no discharge plans. The Nursing Home Administrator and Director of Nursing acknowledged the lack of documentation and the failure to assess the resident in person. The facility's refusal to readmit the resident after hospitalization was not properly documented, and the resident's family was not informed of the discharge decision until contacted by the hospital.
Failure to Permit Resident Readmission After Hospitalization
Penalty
Summary
The facility failed to permit the readmission of a resident after hospitalization, violating transfer and discharge rights. The resident, who had been living in the facility since June 2023, was diagnosed with multiple sclerosis, dysphagia, autistic disorder, dysarthria, ADHD, irritability, bipolar disorder, anxiety, insomnia, and depression. Despite being a long-term care resident with no plans to discharge elsewhere, the facility did not allow the resident to return after an emergency hospital transfer due to behavioral issues. The resident was initially transferred to the hospital on 08/19/2024 following aggressive and suicidal behavior, as documented by the psychiatric provider. The facility's policy indicated that such transfers are not considered discharges, and efforts should be made to ascertain the resident's condition and needs upon return. However, the facility did not document any evaluations or assessments related to the resident's condition after the transfer on 09/01/2024, nor did they develop a discharge plan, as the resident was not expected to leave the facility permanently. Interviews with facility staff revealed that the Nursing Home Administrator and Director of Nursing decided not to readmit the resident due to safety concerns, citing the resident's ability to learn the door code and exit the building. Despite the hospital's assessment that the resident did not exhibit behaviors warranting further psychiatric hospitalization, the facility maintained that they could not ensure the resident's safety. The lack of documentation and failure to follow the facility's policy on transfers and discharges contributed to the deficiency identified by surveyors.
Failure to Provide Written Transfer and Discharge Notice
Penalty
Summary
The facility failed to provide a written transfer and discharge notice to the resident's representative and a copy to the Office of the State Long-Term Care Ombudsman for a resident reviewed for transfer and discharge rights. The resident, who had multiple diagnoses including multiple sclerosis, dysphagia, and bipolar disorder, was admitted to the facility in June 2023. The resident's care plan indicated that he was to remain in the facility for long-term care. However, an involuntary examination was initiated on September 1, 2024, due to concerns about the resident's safety and the facility's inability to meet his needs. The resident was transferred to a hospital, but the required written notice was not provided to the resident's family or the LTC Ombudsman. Interviews with the resident's family member and facility staff revealed a lack of communication and documentation regarding the resident's discharge. The family member was informed by phone about the hospital transfer but was unaware that the resident would not be allowed back to the facility until contacted by the hospital. The facility's Social Services Director and Nursing Home Administrator confirmed that there was no discharge plan for the resident, as he was expected to remain in the facility. The facility's policy stated that notice should be given as soon as practicable, but this was not adhered to in this case.
Medication Errors Lead to Hospital Readmissions
Penalty
Summary
The facility failed to prevent significant medication errors for a resident who was admitted for intravenous antibiotic administration and treatment of opioid abuse with withdrawals. The resident was supposed to receive Suboxone, a combination of buprenorphine and naloxone, at a dosage of 8-2 mg sublingually three times a day. However, due to a transcription error, the facility administered only 2 mg of buprenorphine twice a day, which was not the correct medication or dosage. This error led to the resident experiencing severe withdrawal symptoms and being readmitted to the hospital multiple times. Additionally, the facility failed to administer the resident's prescribed antibiotic, vancomycin, according to the hospital's discharge instructions. The vancomycin was ordered with an incorrect stop date, resulting in the resident missing doses. This oversight contributed to the resident's deteriorating condition, including symptoms such as nausea, seeing halos, shortness of breath, chest pain, and clammy skin, which necessitated further hospital readmissions. The errors were compounded by a lack of communication and understanding among the facility's staff regarding the resident's medication orders. Despite the resident's repeated complaints about not receiving the correct dosage of Suboxone, the facility continued to administer the incorrect medication. The Director of Nursing later identified the transcription error and acknowledged the misunderstanding of the hospital's orders, which should have been clarified with the hospital or pharmacy to ensure the resident received the appropriate treatment.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an infection prevention and surveillance program for six consecutive months. The Nursing Home Administrator (NHA) and the Director of Nursing (DON) both admitted that there was no staff with completed or ongoing infection prevention training. The DON, who started her position recently, lacked formal training and certification in infection control. She was uncertain about the necessary documentation for infection prevention and had not conducted any infection surveillance since her tenure began. The last infection control documentation found was from October 2022, and attempts to gather antibiotic reports were unsuccessful due to incomplete data from the electronic medical record and pharmacy systems. The facility's infection control guidelines had not been reviewed or updated with current evidence-based practices. The Surveillance for Infections policy, last revised in September 2017, was outdated, and the Infection Control Guidelines for All Nursing Procedures policy had not been revised since August 2012. During a lunch meal service observation, a Certified Nursing Assistant (CNA) failed to perform hand hygiene between serving meal trays to residents, citing a lack of soap in residents' rooms and hand sanitizer only being available at the facility's entrance. Enhanced barrier precautions were not in place for two residents with intravenous lines. Resident #347, who was receiving intravenous antibiotics for endocarditis, had no precaution signs or personal protective equipment (PPE) available outside her room. Similarly, Resident #31, who was receiving intravenous antibiotics, had no PPE supplies other than surgical gloves, and no enhanced barrier precautions signage was displayed. Staff involved in the care of these residents were unaware of enhanced barrier precautions and had not received any training or educational in-service regarding them. The facility's infection control policy from 2012 did not reference enhanced barrier precautions.
Lack of Qualified Infection Preventionist in Facility
Penalty
Summary
The facility failed to have a qualified Infection Preventionist responsible for the infection prevention and control program. During an interview, the Nursing Home Administrator (NHA) admitted that no staff member had completed or started infection prevention training. The current Director of Nursing (DON) began her role in late July or early August 2024 and had not conducted any infection surveillance. The NHA was unsure when the last infection surveillance was conducted. The DON, who started as a Unit Manager in mid-July and became the interim DON shortly after, confirmed she lacked formal training and certification in infection control. She was registered for certification but had not started due to uncertainty about which course to take. The DON had not gathered infection control documentation until after the survey entry, with the last available documentation from October 2022. Attempts to run antibiotic reports for July were unsuccessful due to incomplete data from the electronic medical record and pharmacy systems. The facility's infection prevention documentation did not show completed education, training, experience, or certification for the DON.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment for its residents, as evidenced by multiple observations and interviews. On several occasions, surveyors observed significant deficiencies in the physical condition of resident rooms and common areas. These included holes in walls, separated wall borders, chipped paint, rusted grab bars, and broken or missing blinds. Additionally, there were reports of exposed cable cords, broken dressers, and stained or missing floor tiles. The presence of insects and trash in certain areas further highlighted the lack of cleanliness and maintenance. Interviews with the Maintenance Director revealed a lack of regular room audits and an absence of a structured maintenance schedule. The Maintenance Director admitted to not having conducted any room audits since assuming the position and acknowledged the need for repairs and painting. However, he cited a lack of time and resources as barriers to completing these tasks. The director also mentioned the absence of an assistant and a formal policy outlining his responsibilities, which contributed to the backlog of maintenance issues. The facility's policies on maintaining a homelike environment and environmental housekeeping were not effectively implemented. The policies outlined responsibilities for housekeeping and management to ensure a clean and safe environment, but these were not adhered to, as evidenced by the numerous deficiencies observed. The lack of adherence to these policies resulted in an environment that was neither safe nor comfortable for the residents, as demonstrated by the various maintenance and cleanliness issues documented during the survey.
Deficiency in PASRR Completion for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure the accuracy and completion of the Level I Pre-Admission Screening and Resident Review (PASRR) for residents with mental disorders or intellectual disabilities. This deficiency was identified for nine residents out of a sample of twenty. The PASRR process was incomplete or missing for several residents, including those with diagnoses such as major depressive disorder, generalized anxiety disorder, schizophrenia, and other psychiatric conditions. For instance, Resident #4's PASRR did not include updated psychiatric diagnoses, and Resident #27's PASRR did not reflect their diagnosis of depression. The report highlights that some residents admitted during the COVID-19 1135 waiver period did not have PASRRs completed, as the facility misunderstood the requirements post-waiver. Resident #35, admitted during the waiver period, did not have a PASRR completed after the waiver ended. Additionally, Resident #25 and Resident #7 were admitted without PASRRs, and the facility failed to complete these assessments even after the waiver period concluded. The Nursing Home Administrator (NHA) acknowledged the oversight and the lack of an Admissions Director, which contributed to the failure in completing PASRRs. Interviews with facility staff, including the Social Services Director and the NHA, revealed a lack of clarity regarding responsibility for PASRR completion. The NHA admitted to being unaware of the requirement to complete PASRRs for residents admitted during the waiver period. The facility's PASRR policy was found to be undated and contained grammatical errors, indicating potential issues with policy communication and implementation. The absence of an Admissions Director further exacerbated the situation, leaving the NHA to cover the role without adequate support or training.
Delayed MDS Assessment Completion and Transmission
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed and transmitted in a timely manner for two residents. Resident #33's Quarterly MDS Assessment was due on 07/15/2024 but was not completed and transmitted until 08/20/2024. Similarly, Resident #20's assessment, scheduled for the same date, was also delayed and finalized on 08/20/2024. Staff A confirmed that the assessments were finalized but not transmitted due to an oversight, while Staff B acknowledged the error and confirmed that the assessments were not completed within the expected 14-day timeframe.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Resident Assessment Minimum Data Set (MDS) for two residents. For Resident #10, the MDS assessments inaccurately indicated the presence of an indwelling catheter, despite the resident not having one since shortly after her admission. Interviews with staff and the resident confirmed the absence of a catheter, and a physician's order dated 08/27/2024 corroborated this by discontinuing the catheter order. The Regional Director of Clinical Reimbursement and the RN/MDS Coordinator were unable to provide an explanation for the discrepancy in the MDS assessments. For Resident #9, the MDS inaccurately reflected the use of bed rails, marking them as not used, despite the resident's reliance on bilateral enabler rails for bed mobility and balance. The resident's care plan and side rail assessment were inconsistent with the MDS, as the care plan indicated the resident required assistance with dressing and the side rail assessment was incomplete. The resident confirmed using the enabler rails for support during an interview, highlighting the inaccuracy in the MDS documentation. These inaccuracies in the MDS assessments for both residents indicate a failure in the facility's assessment processes, leading to discrepancies between the documented care needs and the actual conditions and requirements of the residents. The reliance on inaccurate source documentation and incomplete assessments contributed to these deficiencies, as evidenced by the interviews and record reviews conducted during the survey.
Deficiencies in Care Plan Implementation for Residents
Penalty
Summary
The facility failed to develop and implement effective care plans for two residents, leading to deficiencies in their care. Resident #35, who has a history of traumatic brain injury and moderate cognitive impairment, was observed multiple times with his bed in a high position, contrary to his care plan which required the bed to be kept in the lowest position to prevent falls. Staff, including a CNA and the DON, were unaware of this care plan requirement, indicating a lack of communication and adherence to the care plan. Resident #24, who is cognitively intact and has a history of bipolar disorder and anxiety, was observed smoking unsupervised with a latex glove on her hand due to a staph infection. Her smoking evaluation was incomplete, and there was no smoking care plan in place, as confirmed by the Regional Director of Clinical Reimbursement. The Social Services Director, responsible for smoking evaluations, did not complete the care plan, highlighting a gap in the facility's process for ensuring resident safety and care plan development.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide adequate assistance to a resident with maintaining good grooming and personal hygiene. The resident, who has medical diagnoses including cerebral palsy, dementia, and major depressive disorder, was observed multiple times with overgrown facial hair and fingernails, and substances under his nails. Despite the resident expressing a preference for being clean-shaven and having trimmed nails, these needs were not met. Observations on different days confirmed the resident's unkempt appearance, and staff interviews revealed inconsistencies in the documentation and execution of personal care tasks. Staff members, including a CNA and an LPN, acknowledged the resident's need for grooming but cited issues such as poor eyesight and lack of resources like towels as barriers to providing care. The resident's care plan indicated a need for assistance due to functional limitations, yet there was no documentation of nail trimming or shaving for the month. The DON confirmed that residents should receive showers as scheduled and be clean and groomed according to their preferences, but the facility's documentation practices did not reflect this standard of care.
Oxygen Therapy Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide oxygen according to physician's orders for a resident with chronic obstructive pulmonary disease (COPD) and other medical conditions. The resident was observed with an oxygen concentrator set to 3.5 liters per minute (LPM), while the physician's orders specified continuous oxygen up to 5 LPM to maintain oxygen saturation above 90% and 2 LPM as needed if saturation fell below 92%. The resident's nurse confirmed the discrepancy and adjusted the oxygen level to 2 LPM, which resulted in an oxygen saturation of 93%. The Director of Nursing (DON) acknowledged the inconsistency with the physician's orders. Another deficiency was identified when a resident with chronic respiratory failure and COPD was observed using petroleum jelly while on oxygen therapy. The resident's physician's order required continuous oxygen at 4 LPM via nasal cannula. Petroleum jelly, a flammable product, was found on the resident's bedside table, which contradicts the facility's oxygen safety policy that prohibits the use of oil-based products near oxygen. The DON and nursing staff were unaware of the flammability risk associated with petroleum products, despite the facility's policy and guidelines from the American Lung Association. Interviews with staff revealed a lack of awareness and training regarding the facility's oxygen policy and the risks associated with flammable products near oxygen. The DON and the Nursing Home Administrator (NHA) were not fully informed about the training procedures for staff on oxygen safety. The facility's policy clearly states the need to remove all potentially flammable items from areas where oxygen is administered, yet this was not adhered to, leading to the identified deficiencies.
High Medication Error Rate Observed
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 48% error rate observed during a survey. During the medication administration observation, Staff M, an LPN, was responsible for administering medications to two residents. For Resident #35, Staff M administered an incorrect dosage of Lactulose, providing only 25 mL instead of the prescribed 30 mL. Additionally, two medications, B complex vitamin C-folic acid and Potassium citrate, were missing from the medication cart, and Staff M was unaware of the error until it was pointed out. The medication administration history indicated that the Potassium citrate was signed off late, although it was reportedly administered on time. For Resident #25, Staff M administered several medications but was missing Ascorbic Acid vitamin C, which had been discontinued on the day of observation. Staff M was observed taking the resident's blood pressure before administering Metoprolol and other medications, but expressed being behind schedule. The medication administration record confirmed the discontinuation of Ascorbic Acid on the same day. Interviews with staff revealed that the medication pass on the North unit was particularly heavy, contributing to delays and errors. The Director of Nursing acknowledged the issues with medication administration timeliness and the challenges faced by nurses with the Electronic Medication Administration Record (EMAR) system. The facility's policy requires medications to be administered safely, timely, and as prescribed, within one hour of the scheduled time. However, the observations and interviews indicated that these standards were not consistently met, leading to the high medication error rate.
Failure to Secure Bed Rails for Resident
Penalty
Summary
The facility failed to ensure the safety of bed rails for a resident, as observed during a survey. On a specific date, the resident demonstrated that the right enabler rail on their bed was loose and could be moved easily, which they had reported multiple times to the Nursing Home Administrator (NHA) and maintenance without resolution. The resident, who uses the rail to aid in mobility, expressed fear of using it due to its instability. The resident's electronic medical record indicated an admission with diagnoses including lymphedema, unspecified convulsions, restless agitation, and cellulitis of the right lower limb, with a BIMS score indicating no cognitive impairment. The Maintenance Director (MD) had signed off on audits indicating that bed rails were checked, but no work orders were completed for the resident's bed rails in the maintenance log for the past three months. The MD stated that he performs monthly audits and had tightened the resident's bed rail only after the surveyor brought the issue to the NHA's attention. The facility's undated Nursing Home Side Rail Policy requires regular inspection of side rails to ensure they are functioning properly and safely, with any issues to be reported and addressed immediately.
Call Light System Malfunction
Penalty
Summary
The facility failed to ensure that the call light system was functioning properly in the bathroom and room of a resident. During an observation, the resident attempted to use the call light in her bathroom, but it did not activate to alert staff. The resident reported that her call light has not worked for a long time and that it often activates in the neighboring room instead, causing delays in receiving assistance. The resident has experienced waits of up to an hour due to this malfunction. The facility had installed a new call light system earlier in the year, which was not installed correctly, resulting in crossed wiring. Staff were aware of the issue and were instructed to check both rooms when the call light was activated. The Maintenance Director confirmed the wiring problem and stated that he had contacted the corporate office to address the issue. The Nursing Home Administrator was also aware of the problem, but the facility did not have a call light policy to address this deficiency.
Inadequate Pest Control Program Leads to Flying Insect Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flying insects in resident rooms and common areas over a four-day period. Observations revealed that a resident was frequently surrounded by flying insects, which landed on his clothing and disturbed his daily activities. The resident reported that the insects had been a persistent issue for months, and he had not observed any pest control measures being taken. Photographic evidence was obtained to support these observations. Another resident expressed concerns about flies entering her room from a nearby bedframe, which affected her ability to sleep and eat. Interviews and record reviews indicated that the facility's pest control program was inadequate. The Maintenance Director stated that the pest control company visited monthly and as needed, with the last visit recorded on 8/23/24. However, the pest control log showed ongoing issues with various flying insects throughout the facility, with no documentation of treatment for these pests. The most recent pest control service focused solely on rodent bait stations, neglecting the issue of flying insects. This lack of effective pest control measures contributed to the ongoing presence of flying insects in resident areas.
Failure to Assess and Plan for Self-Administration of Medications
Penalty
Summary
The facility failed to assess and implement a process for residents to self-administer medications, as evidenced by the cases of two residents. Resident #51, who was admitted with diagnoses including acute bronchitis and anxiety disorder, was observed with a bottle of nasal spray on his bedside table, which his family had brought in. The Director of Nursing (DON) confirmed that the resident had not been evaluated for self-medication, and there was no physician's order or care plan intervention for self-medicating. Similarly, Resident #50, admitted with conditions such as chronic pain and schizoaffective disorder, was observed self-administering eye drops without an evaluation for self-medication or a corresponding care plan intervention. The facility's policy requires an interdisciplinary team assessment and physician's order for residents to self-administer medications, which was not followed in these cases. The DON acknowledged that none of the current residents had been evaluated for self-medication, and the facility's policies on administering and self-administering medications were not adhered to. This lack of assessment and planning led to the deficiency, as the facility did not ensure that residents were evaluated for their capability to safely self-administer medications.
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.
