Golfcrest Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hollywood, Florida.
- Location
- 600 North 17th Ave, Hollywood, Florida 33020
- CMS Provider Number
- 105009
- Inspections on file
- 20
- Latest survey
- May 21, 2025
- Citations (last 12 mo.)
- 0
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.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
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