Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Golfcrest Nursing Center during CMS and state inspections, most recent first.
A resident with recent major surgery and complex care needs was admitted without timely physician orders for pain management, surgical site care, or Foley catheter care. Facility staff did not complete required pain assessments or administer routine and as-needed medications until the day after admission, despite clear hospital discharge instructions and family concerns. Nursing staff acknowledged not contacting the physician or documenting pain assessments as required by facility policy.
The facility failed to provide adequate care, including timely medication administration, accurate skin condition documentation, and proper nutritional support. A resident experienced a delay in receiving medication after abnormal lab results, another had exposed skin areas not documented, and a third suffered significant weight loss due to inadequate nutritional assessments and interventions.
A facility failed to provide timely nutritional assessments and interventions, leading to significant weight loss for a resident. Inconsistent application of dietary orders and inaccurate recording of food intake contributed to the deficiency. Another resident had overlapping enteral feeding orders, resulting in improper administration, while a third resident's feeding regimen was not followed, despite a risk for malnutrition. The facility's failure to adhere to physician orders and properly monitor feeding regimens led to these nutritional deficiencies.
The facility failed to develop and implement comprehensive care plans for two residents. One resident's care plan was not updated to address a resolved skin condition and lacked preventive measures for new issues. Another resident had no care plan for medications prescribed for agitation, with no monitoring for side effects. The MDS Coordinator acknowledged these oversights.
The facility was found deficient in maintaining a safe, clean, and homelike environment for residents. Observations revealed issues such as peeling paint, dust-covered fans and vents, uncovered fluorescent bulbs, missing light bulbs, unpainted plaster, leaky faucets, and improperly wrapped call light cords. These findings were acknowledged by the new Director of Maintenance and Administrator during a tour with surveyors.
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency in accommodating their needs. One resident was observed with the call light out of reach multiple times, requiring them to yell for assistance. Another resident was found banging on her table and yelling for help due to an inaccessible call light. Staff interviews confirmed that call lights should be within reach, but this was not the case for these residents.
The facility failed to provide a safe, clean, and homelike environment for residents, with issues such as peeling paint, dusty fans, uncovered fluorescent bulbs, and leaky faucets observed in several rooms. These deficiencies were acknowledged by the new Director of Maintenance and Administrator.
A facility failed to develop and implement comprehensive care plans for two residents. One resident's care plan was not updated to reflect the resolution of a skin condition, and there were no preventive interventions. Another resident had no care plan for medications prescribed for agitation, lacking monitoring for behaviors and side effects. The MDS Coordinator acknowledged these deficiencies.
A facility failed to promptly notify a physician and administer medication to a resident with abnormal lab results, resulting in a seven-day delay. Additionally, the facility did not accurately document the condition of another resident with a skin condition, despite physician's orders for wound care. The deficiencies were due to a lack of communication, documentation, and adherence to facility policies.
A resident with Type 2 diabetes and mobility issues did not receive adequate care to prevent skin integrity problems. The facility failed to document necessary interventions like turning and repositioning, and staff interviews revealed inconsistencies in care protocols and documentation. The lack of proper documentation and communication contributed to the deficiency.
The facility failed to monitor side effects and behaviors for residents on medications. A resident with nervous system disorder and agitation was not monitored for side effects until later, despite receiving medication. Another resident with heart failure had no interventions to monitor medication side effects, as the facility did not follow a protocol for such monitoring. A third resident on antipsychotic medication was not monitored for adverse reactions, with the DON acknowledging the lack of documentation.
A CNA failed to wear a protective gown while performing peri-care on a resident with a biliary drain, despite the facility's infection control policies requiring enhanced barrier precautions. Another CNA intervened by providing the gown, and the DON confirmed the need for proper PPE use.
A facility failed to maintain compliance with NFPA 101 standards as a main lobby door with a 15-second delayed egress lock was missing required signage. This was observed during a facility tour with the Maintenance Director, who acknowledged the deficiency.
The facility did not maintain documentation for the required five-year internal backflow preventer inspection of their Automatic Fire Sprinkler System (AFSS), as observed during a record review with the Maintenance Director. The absence of this documentation was acknowledged by the Maintenance Director during the inspection.
The facility failed to maintain and test their Essential Electrical System as per NFPA 99 standards, with no documentation available for the monthly generator conductance test. The Maintenance Director acknowledged the findings during a record review, indicating a lapse in required maintenance procedures.
Failure to Obtain and Document Timely Admission Physician Orders and Pain Management
Penalty
Summary
The facility failed to obtain and document timely physician orders for immediate care upon the admission of a resident who had recently undergone major spinal surgery and had complex medical needs, including a surgical site with staples and a Foley catheter. Despite the resident's transfer from the hospital with clear medication orders for pain management and other routine medications, the facility did not enter these orders into their system or administer the medications until the day after admission. There was no evidence that the facility contacted the physician to obtain necessary orders for pain medication, surgical site care, or Foley catheter care at the time of admission. The resident was admitted in the evening, alert and oriented, but dependent for all activities of daily living and with a history of metastatic cancer and recent surgery. Family members reported that the resident experienced significant pain upon admission, and that pain medication was not provided despite their concerns and communication with facility staff. Nursing documentation and interviews confirmed that pain assessments were not completed as required by facility policy, and that no pain reassessment or documentation occurred during the initial shift. The nurse responsible for the admission acknowledged forgetting to contact the physician for orders and failing to reassess or document the resident's pain. Further review of the medical record showed that none of the resident's routine or as-needed medications, including those for pain, were administered until the following day. The facility's own policies required pain observation and documentation at admission and when pain status changed, but these steps were not followed. Interviews with staff and the DON confirmed that the expected process was not carried out, resulting in a lack of timely physician orders and medication administration for the resident's immediate care needs.
Deficiencies in Medication Administration, Skin Care, and Nutritional Support
Penalty
Summary
The facility failed to provide adequate and appropriate health care to its residents, as evidenced by several deficiencies. One significant issue involved a resident who did not receive timely notification and administration of medication following abnormal lab results. The resident's lab results were reported to the facility, but there was a delay of approximately one week before the medication was administered. The facility's process for handling abnormal lab results was not followed, as there was no documentation of the physician being notified promptly, and the medication order was not entered into the system in a timely manner. Another deficiency was observed in the care of a resident with a skin condition. The facility failed to accurately document and assess the status and condition of the resident's skin. Observations revealed exposed and uncovered areas on the resident's skin, but there was no mention of these in the nursing progress notes. The facility's documentation did not reflect the current status or condition of the resident's skin, and there was no specific care plan in place for the resident's surgical site. Additionally, the facility did not ensure proper nutritional assessments and interventions for a resident, resulting in significant weight loss. The resident experienced a severe weight loss over several months, and the facility's documentation and monitoring of the resident's nutritional intake were inadequate. The resident's daughter expressed concern about the weight loss and the lack of communication regarding her mother's dietary preferences and needs. The facility's failure to follow physician's orders for nutritional support further contributed to the resident's decline in health.
Plan Of Correction
Resident #16 received ordered completed on with no adverse effects. Resident #2 surgical site was dressed and documented on with suture removal. Audit of residents with surgical sites for documentation and care plan development and implementation. Audit of residents with current orders for completion of physician notification and prompt start of if indicated. 100% Inservice for all licensed nurses on results with prompt physician notification and prompt start of ordered treatment. 100% Inservice for all licensed nurses for documentation of surgical sites and care plan development and implementation for surgical sites. DON or designee to audit weekly for results to physician with prompt start of ordered treatment and surgical site documentation with care plan development and implementation. DON or designee to report findings of all audits to QAPI committee meeting monthly. Resident #37 care plan updated for maintenance and prevention. 100% audit of residents with, for development and implementation of care plans as identified. 100% Inservice of all licensed nursing staff for care plan development and implementation for. DON or designee to audit residents with for care plan development and implementation weekly for 30 days and monthly ongoing. DON or designee to report findings of care plan audits to QAPI committee meeting monthly. Resident #51 was sent to hospital on as of. Resident #51 remains in hospital. Resident #167 and #169 orders for feeding were clarified and corrected on. 100% audit of all feeding residents for orders to meet nutritional needs, one order and RD documentation. Inservice DON and Registered Dietician of documentation and feeding order requirements. DON or designee to audit for feeding orders and RD documentation with feeds weekly times 4 weeks and then monthly ongoing. DON or designee to report findings of audits to QAPI committee meeting monthly.
Nutritional Deficiencies Due to Inadequate Monitoring and Feeding Regimen
Penalty
Summary
The facility failed to provide timely nutritional assessments and interventions, resulting in significant weight loss for a resident. The resident experienced a severe weight loss of 25.2% over eight months, with various dietary orders being inconsistently applied or discontinued without adequate follow-up. The resident's nutritional needs were not met, and there was a lack of consistent monitoring and adjustment of feeding regimens. Observations revealed that the resident's food intake was often inaccurately recorded, and the resident's preferences and dislikes were not adequately addressed, contributing to the nutritional deficiency. Another resident had overlapping orders for enteral feeding, leading to confusion and improper administration of nutritional support. The resident's feeding regimen was not consistently followed, with discrepancies in the amount of formula administered. The facility's staff failed to recognize and correct these issues, resulting in inadequate nutritional support for the resident. A third resident also experienced issues with enteral feeding, with observations showing that the prescribed feeding regimen was not followed. The resident's nutritional assessment indicated a risk for malnutrition, yet the recommended adjustments to the feeding regimen were not implemented. The facility's failure to adhere to physician orders and properly monitor and adjust feeding regimens contributed to the nutritional deficiencies observed in these residents.
Plan Of Correction
Resident #51 was sent to hospital on Resident #51 remains in hospital as of Resident #167 and #169 orders for feeding were clarified and corrected on 100% audit of all feeding residents for orders to meet nutritional needs, one order and RD documentation. Inservice DON and Registered Dietician of documentation and feeding order requirements. DON or designee to audit for feeding orders and RD documentation with feeds weekly times 4 weeks and then monthly ongoing. DON or designee to report findings of audits to QAPI committee meeting monthly.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in their care. For one resident, the care plan was not updated to reflect the resolution of a skin condition, and there were no interventions in place to prevent the development of new skin issues. The resident had a history of immobility and skin conditions, but the care plan did not include necessary updates or preventive measures. The MDS Coordinator acknowledged the oversight and stated that care plans should be updated within a couple of days when new issues arise. For another resident, the facility did not have a care plan in place for medications prescribed for agitation and restlessness. The resident had multiple medication orders, but there were no interventions documented to monitor for behaviors or side effects. The MDS Coordinator confirmed that a care plan should have been in place for the medications, including monitoring for potential side effects. This lack of a comprehensive care plan for medication management was identified as a deficiency during the survey.
Plan Of Correction
Resident #37 care plan updated for maintenance and prevention and Resident #59 care plan developed and implemented for medications. 100% audit of residents with medications and for development and implementation of care plans as identified. 100% Inservice of all licensed nursing staff for care plan development and implementation for medications. DON or designee to audit residents on medications and for care plan development and implementation weekly for 30 days and monthly ongoing. DON or designee to report findings of care plan audits to QAPI committee meeting monthly.
Deficiencies in Facility Environment and Maintenance
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several observations made during a survey. In six of the 27 resident rooms observed, issues were noted such as unsmooth and peeling paint on walls, dust and debris covering standing fans and A/C vents, and uncovered fluorescent bulbs in entryways. Additionally, some rooms had missing light bulbs, unpainted plaster on bathroom walls, and leaky faucets in bathroom sinks. Further observations revealed that call light pull cords were improperly wrapped around grab bars in bathrooms, which could potentially hinder their use. These deficiencies were acknowledged by the Director of Maintenance, who had been at the facility for 1.5 weeks, and the Administrator, who had started the week of the survey. Both acknowledged the findings during a side-by-side tour of the facility with the surveyors.
Plan Of Correction
Light bulbs replaced in Light covers replaced in and 24, 33 Standing fan cleaned in Walls smoothed and painted in Leaking faucet fixed in , and Call light pull cord removed from grab bar in Resident room environmental rounds completed by Administrator and Maintenance Director. Inservice Administrator and Maintenance Director on preventative maintenance rounds and correcting maintenance concerns. Administrator or designee to perform resident room environmental rounds weekly for 30 days, and monthly ongoing. Administrator or designee to report findings of environmental rounds to QAPI committee meeting monthly.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a deficiency in accommodating resident needs and preferences. Resident #10 was observed multiple times with the call light draped behind the bed and out of reach. Despite being able to use the call bell, the resident could not reach it and had to resort to yelling for assistance. Interviews with staff confirmed that call lights are supposed to be within reach of residents at all times, yet this was not the case for Resident #10. Similarly, Resident #2 was observed banging on her overbed table and yelling for help because she needed to go to the bathroom. The call light was clipped to the top corner of her pillow, making it inaccessible. When a CNA entered the room, she found the call light hanging off the bed and handed it to the resident, who then used it to call for assistance. The resident's inability to reach the call light led to her distress and need for immediate help.
Plan Of Correction
Call lights for resident #2 and #10 were placed within reach of the residents. Audit of 100% of residents that their call lights were in reach. Educate 100% of staff to place call lights within reach of residents. Call light observation audits to be performed by DON or designee 5 times per week for 30 days, and then monthly ongoing. DON or designee to report findings of call light observation audits to QAΡΙ committee meeting monthly.
Deficiencies in Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed in 6 out of 27 resident rooms. Observations included unsmooth and peeling paint on the wall behind a bed, a standing fan covered with dust and debris, and uncovered fluorescent bulbs in entryways. Additionally, there were issues with cleanliness and maintenance, such as A/C vents covered with dust and debris, a lightbulb out in a bathroom, unpainted plaster on a bathroom wall, and leaky faucets in bathroom sinks. Further observations revealed a missing light bulb in an entryway and a call light pull cord wrapped around a grab bar in a bathroom. These deficiencies were acknowledged by the Director of Maintenance, who had been at the facility for 1.5 weeks, and the Administrator, who started the week of the survey. The report highlights the facility's failure to maintain a sanitary, orderly, and comfortable environment, as required by the regulations.
Plan Of Correction
F584/N110 Light bulbs replaced in Light covers replaced in Standing fan cleaned in 24, 33 Walls smoothed and painted in Leaking faucet fixed in Call light pull cord removed from grab bar in Resident room environmental rounds completed by Administrator and Maintenance Director. Inservice Administrator and Maintenance Director on preventative maintenance rounds and correcting maintenance concerns. Administrator or designee to perform resident room environmental rounds weekly for 30 days, and monthly ongoing. Administrator or designee to report findings of environmental rounds to QAPI committee meeting monthly.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in their care. Resident #37 was admitted with diagnoses including Type 2 diabetes and unspecified abnormalities of gait and mobility. The care plan for this resident was not updated to reflect the resolution of a skin condition, and there were no interventions in place to prevent the development of new skin issues. The MDS Coordinator acknowledged that the care plan should have been updated and resolved earlier. Resident #59, who was admitted with degenerative nervous system issues and restlessness, had no care plan in place for medications prescribed for agitation and restlessness. The MDS Coordinator confirmed that there should have been a care plan to monitor for behaviors and side effects related to these medications. The lack of a care plan for medication management was acknowledged as a deficiency by the MDS Coordinator. Interviews with the MDS Coordinator revealed that care plans should be updated within a couple of days when new issues arise, and that there should be interventions in place for residents with a history of skin issues. The failure to update and implement comprehensive care plans for these residents indicates a lapse in the facility's adherence to regulatory requirements for person-centered care planning.
Plan Of Correction
Resident #37 care plan updated for maintenance and prevention and Resident #59 care plan developed and implemented for medications. 100% audit of residents with medications and for development and implementation of care plans as identified. 100% Inservice of all licensed nursing staff for care plan development and implementation for medications. DON or designee to audit residents on medications and for care plan development and implementation weekly for 30 days and monthly ongoing. DON or designee to report findings of care plan audits to QAPI committee meeting monthly.
Failure to Notify Physician and Document Resident Care
Penalty
Summary
The facility failed to promptly notify the ordering physician and administer medication to a resident with abnormal lab results. Resident #16, who was re-admitted with diagnoses including Type 2 diabetes with complications, experienced a delay in receiving oral medication. The lab results indicating an abnormal culture were reported to the facility, but the medication was not administered until seven days later. The delay was due to a lack of documentation and communication among the nursing staff, as well as the absence of a tracking system for abnormal lab results. Additionally, the facility failed to accurately document and assess the status and condition of a resident with a skin condition. Resident #2, who had a severe cognitive impairment, was observed with exposed and uncovered areas on her left lower extremity. Despite the presence of physician's orders for wound care, there was no documentation of the existence, presence, or condition of the resident's wounds in the nursing progress notes. The lack of documentation and assessment of the resident's skin condition was acknowledged by the Director of Nursing. The deficiencies highlight the facility's failure to adhere to its policies and procedures for communicating urgent lab results and documenting resident care. The absence of a care plan for Resident #16's medication and Resident #2's wound care further contributed to the deficiencies. The Director of Nursing acknowledged the need for prompt notification of physicians and detailed documentation of residents' conditions.
Plan Of Correction
Resident #16 received ordered completed on with no adverse effects. Resident #2 surgical site was dressed and documented on with suture removal. Audit of residents with surgical sites for documentation and care plan development and implementation. Audit of residents with current orders for completion of physician notification and prompt start of indicated treatment. 100% Inservice for all licensed nurses on results with prompt physician notification and prompt start of ordered treatment. 100% Inservice for all licensed nurses for documentation of surgical sites and care plan development and implementation for surgical sites. DON or designee to audit weekly for prompt notification of results to physician with prompt start of ordered treatment and surgical site documentation with care plan development and implementation. DON or designee to report findings of all audits to QAPI committee meeting monthly.
Failure to Prevent Skin Integrity Issues
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards to prevent skin integrity issues. Resident #37, who was admitted with diagnoses including Type 2 diabetes and unspecified abnormalities of gait and mobility, was not provided with adequate care to prevent the development of skin conditions. The resident's records showed a lack of documentation for turning and repositioning, which are critical interventions for preventing skin breakdown. The Treatment Administration Record for the month in question did not document the care provided, and the Care Plan did not include measures for skin condition prevention. Interviews with facility staff revealed inconsistencies in the documentation and execution of care protocols. The Assistant Director of Nursing acknowledged that weekly skin checks were not performed as ordered, and there was no documentation of care being performed as required. Additionally, the Certified Nursing Assistant and Registered Nurse indicated that there was no designated place in the electronic medical record to document turning and repositioning. The Director of Nursing and an Advanced Registered Nurse Practitioner provided conflicting information about the resident's skin condition, further highlighting the lack of proper documentation and communication within the facility.
Plan Of Correction
Resident #37 orders updated for turning and repositioning every 2 hours as tolerated to allow for CNA documentation and care plan developed and implemented for 100% audit with, for turning and repositioning documentation and care plan development and implementation. Inservice 100% of licensed nurses on turning and repositioning order entry for CNA documentation and care plan development and implementation for DON or designee to audit orders for turning and repositioning to allow documentation by CNAs and care plan development and implementation for 2 times weekly for 30 days, and then monthly ongoing. DON or designee to report findings of audits to QAPI committee meeting monthly.
Failure to Monitor Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to ensure adequate monitoring of side effects and behaviors for residents receiving medications, as evidenced by the cases of three residents. Resident #59 was admitted with diagnoses including degenerative nervous system disorder and agitation. Despite being prescribed medications for agitation and restlessness, there was no order to monitor side effects or behaviors until a later date. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed that the resident received the medication as ordered, but there was no documentation of behavior or side effect monitoring until a specified date. Additionally, the care plan for Resident #59 lacked interventions to monitor for behaviors or side effects related to the medications. Resident #1, who was admitted with a diagnosis of acute diastolic heart failure and other conditions, had a care plan indicating a need for monitoring potential changes in behavior and side effects due to medication use. However, the facility failed to implement interventions to monitor these changes. The Director of Nursing (DON) stated that monitoring behaviors or side effects for these medications was not part of the protocol followed by the facility. Resident #45, admitted with a diagnosis of moderate cognitive impairment, was prescribed an antipsychotic medication. The care plan indicated the need to monitor for adverse reactions, but the MAR and TAR did not show that the facility was monitoring the side effects and adverse reactions of the medication. The DON acknowledged that there should be an order to monitor side effects, and a registered nurse confirmed that the monitoring was not documented in the electronic system.
Plan Of Correction
Resident #45 had orders clarified for monitoring of side effects of medications. Resident #1 and #59 had orders clarified for monitoring of side effects and behaviors for medications. Audit of 100% of residents with medications for side effect monitoring. Inservice all licensed nursing staff on orders to have side effect monitoring and orders with medications to have side effect and behavior monitoring. DON or designee to audit for side effect monitoring and medications for side effect and behavior monitoring weekly for 4 weeks and then monthly ongoing. DON or designee to report findings of audits to QAPI committee meeting monthly.
Inadequate Use of PPE During Resident Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control program during a high-contact resident care activity. Specifically, a Certified Nursing Assistant (CNA), identified as Staff N, was observed performing peri-care on a resident without wearing the appropriate personal protective equipment (PPE), specifically a protective gown. This occurred despite the resident having a biliary drain in place, which necessitated enhanced barrier precautions. The CNA was only wearing gloves and was in close proximity to the resident's exposed peri-area when another staff member, Staff O, intervened by handing a protective gown through the door. The deficiency was further highlighted during interviews with the staff involved. Staff N was unable to provide a clear explanation for not donning the gown before starting the care procedure. Staff O acknowledged noticing the lack of PPE and acted by providing the gown. The Director of Nursing (DON), who also serves as the Infection Control Nurse, confirmed that the CNA should have worn the gown and mentioned that recent education on infection control procedures, including the use of PPE, had been provided to the nursing staff. The incident was documented with photographic evidence.
Plan Of Correction
Care was provided to resident #171 after a gown was provided to staff N by staff O inservice to nursing staff regarding Enhanced Barrier Precautions and donning gowns prior to care. DON or designee to do observational audits for Enhanced Barrier Precautions with gown donning prior to care 5 times weekly for 30 days and then monthly ongoing. DON or designee to report findings of audits to QAPI committee meeting monthly.
Missing Signage on Delayed Egress Door
Penalty
Summary
The facility failed to maintain egress doors equipped with delayed egress locking arrangements in accordance with NFPA 101 standards. During a facility tour conducted on April 8, 2025, between 1:30 PM and 2:45 PM, it was observed that the main lobby door, which was equipped with a 15-second delayed egress lock, was missing the required signage. This observation was made in the presence of the Maintenance Director, who acknowledged the findings. The deficiency was further discussed with the Maintenance Director during an exit conference held on the same day at 3:00 PM. The lack of required signage on the egress door represents a failure to comply with the NFPA 101 (2021 Edition) 7.2.1.6.1.1(4)(a) standards, which mandate specific requirements for delayed egress locking systems to ensure safety and compliance.
Plan Of Correction
ACTIONS TAKEN TO CORRECT THE DEFICIENCY: All doors will be monitored on a monthly basis to ensure all 15 second signs are posted on the main entry exit egress exit door. HOW OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE WILL BE IDENTIFIED: A Full audit will be completed for all for all residents to ensure that all residents are provided a safe environment. MEASURES PUT INTO PLACE TO ENSURE THE SAME DEFICIENT PRACTICE DOES NOT REOCCUR: Audits will be completed on a monthly basis to ensure the same deficient practice does not re occur. HOW THE CORRECTIVE ACTION WILL BE MONITORED: All audits will be brought to QAPI monthly thereafter.
Failure to Document Five-Year Sprinkler System Inspection
Penalty
Summary
The facility failed to maintain their Automatic Fire Sprinkler System (AFSS) in accordance with NFPA 101 standards. During an inspection on April 8, 2025, it was observed that there was no documentation available for the required five-year internal backflow preventer inspection. This deficiency was identified during a record review conducted with the Maintenance Director, who acknowledged the findings. The lack of documentation for the inspection was discussed with the Maintenance Director during the exit conference on the same day.
Plan Of Correction
NFPA 101 ACTION(S) TAKEN TO CORRECT THE DEFICIENCY: The facility scheduled a 5-year sprinkler backflow on 4/16/2025 and completed on 4/17/2025. HOW OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE WILL BE IDENTIFIED: A full audit was completed to identify all residents with potential to be affected by the deficient practice. The potential for harm was minimal. MEASURES PUT INTO PLACE TO ENSURE THE SAME DEFICIENT PRACTICE DOES NOT REOCCUR: The Maintenance Director or Designee will conduct an audit on an annual basis to ensure the 5-year sprinkler backflow is in compliance. HOW THE CORRECTIVE ACTION WILL BE MONITORED: The Maintenance Director will audit compliance with the 5-year sprinkler back annually for compliance. Findings will be brought to QAPI.
Failure to Document Monthly Generator Conductance Test
Penalty
Summary
The facility failed to maintain and test their Essential Electrical System (EES) in accordance with NFPA 99 standards. During a record review conducted on April 8, 2025, between 10:00 AM and 1:30 PM, it was found that there was no documentation available for the monthly generator conductance test. This deficiency was identified for 1 of 1 monthly generator conductance test, indicating a lapse in the required maintenance and testing procedures. The Maintenance Director was present during the record review and acknowledged the findings. The absence of documentation for the generator conductance test suggests that the facility did not perform or properly record the necessary monthly test to ensure the generator's capability to supply service within the required 10 seconds. This oversight was discussed with the Maintenance Director during the exit conference on the same day.
Plan Of Correction
CFR(s) NFPA 110, 99 ACTION(S) TAKEN TO CORRECT THE DEFICIENCY: Maintenance Director conducted a test on 4/8/2025, 4/16/2025, & 4/21/2025 to ensure the battery conductance test is at the correct voltage and by IPS TAW Generator Company on 4/21/2025. HOW OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE WILL BE IDENTIFIED: The facility conduct a full house audit to identify all residents with the potential to be affected. The potential for harm is minimum. MEASURES PUT INTO PLACE TO ENSURE THE SAME DEFICIENT PRACTICE DOES NOT RECUR: The Maintenance Director will complete the Generator Conductance test on a monthly basis. Findings and the conductance test log will be brought to QAPI for 6 months and then annually thereafter. HOW THE CORRECTIVE ACTION WILL BE MONITORED: All findings will be brought to QAPI for six months and Annually thereafter.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
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| Kindred Hospital South Florida Hollywood | 0.5 mi | ★★★★★ | 0 | 0 |
| Westlake Nursing And Rehab Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Emerald Nursing And Rehabilitation Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Palm Garden Of Aventura | 3.1 mi | ★★★★★ | 0 | 0 |
| Vi At Aventura | 4.3 mi | ★★★★★ | 0 | 0 |
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