Lake City Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake City, Florida.
- Location
- 298 Sw Prosperity Place, Lake City, Florida 32024
- CMS Provider Number
- 106126
- Inspections on file
- 21
- Latest survey
- April 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lake City Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not ensure proper wound care and medication management for several residents. Two residents had wound dressings that were not changed or documented according to physician orders and facility policy, with missing dates and initials on dressings and incomplete skin assessments. Another resident's medication was held by nursing staff without appropriate parameters or physician clarification, contrary to prescriber orders. These deficiencies were confirmed through observations, record reviews, and staff interviews.
Surveyors found that staff failed to properly store respiratory equipment, did not consistently use required PPE for residents on enhanced barrier precautions, and neglected hand hygiene and equipment cleaning protocols. Staff also handled medications with bare hands and administered pills that had dropped onto unclean surfaces, all in violation of facility infection control policies.
The facility did not ensure the accuracy of MDS assessments for three residents, including incorrect documentation of vision status, use of a feeding tube, and oral/dental status. Staff interviews and resident records confirmed that the MDS entries did not accurately reflect the residents' actual conditions.
A resident was admitted with multiple mental health diagnoses, but the facility failed to ensure the Level I PASRR assessment accurately reflected all relevant conditions as documented in the medical record. The Administrator confirmed the facility did not follow its process to review and correct the PASRR upon admission, resulting in noncompliance with federal screening requirements.
The facility did not develop or implement comprehensive care plans for two residents: one with mental health diagnoses requiring monitoring and another needing enhanced barrier precautions for wound care. Staff confirmed these care needs were not addressed in the residents' care plans, contrary to facility policy and federal requirements.
A resident did not receive a physician-agreed pharmacy recommendation for vitamin D3 supplementation, as the order was not entered into the electronic medical record despite documented agreement. Staff interviews confirmed the expectation that such recommendations be acted upon, but the process was not completed as required by facility policy.
A resident continued to receive an extended-release medication without a stop date, despite the consultant pharmacist's recommendation to evaluate the need and consider discontinuation. The physician's responses were inconsistent, and facility staff did not ensure that the medication orders were updated in the electronic medical record, leading to ongoing administration of the drug without adequate justification.
Surveyors found that several residents had unauthorized access to medications and biologicals in their rooms, including sprays, lubricants, powders, and an unattended pill. Staff confirmed that no residents were authorized to self-administer medications, and facility policy required secure storage and proper assessment before allowing self-administration. Medications and biologicals were not stored according to professional standards or facility policy.
A resident was not provided with timely dental services after losing dentures, resulting in the need for a mechanical soft diet. Delays were attributed to insurance and referral processes, and although staff documented the resident's ability to eat, the lack of dentures remained unresolved.
Surveyors found that food items in both the kitchen walk-in freezer and nourishment room refrigerator were not labeled or dated as required by facility policy. The Dietary Manager confirmed that these items should have been labeled and dated, indicating a failure to follow professional standards for food service safety.
A resident who previously participated in a restorative program did not receive required specialized rehabilitative services or evaluations after the program was discontinued, despite active physician orders and care plan interventions indicating ongoing need. Facility staff confirmed that the transition to a new functional maintenance program did not include proper evaluation or continuity of care for this resident, resulting in a lapse in required services.
Surveyors found that staff failed to maintain complete and accurate medical records for several residents, including improper documentation of behavioral monitoring, medication administration, and wound care. Errors included incomplete behavioral documentation, incorrect transcription of a medication order, lack of provider notification documentation when medications were held, and false documentation of wound care based on unverified reports from other staff.
The facility did not maintain an effective QAPI program for monitoring and documenting significant weight loss, as two residents identified for weight loss were not weighed according to the required weekly schedule, and there was no documentation of required risk meetings or monitoring. The DON confirmed the absence of documentation and a set plan during the transition to a new program, resulting in a lack of evidence that the QAPI processes were followed.
The facility did not establish or follow an effective antimicrobial stewardship program, as evidenced by two residents receiving antimicrobials without proper assessment, documentation, or diagnostic testing. Staff interviews indicated that providers often prescribed antimicrobials without required testing or review, and facility policy requirements for monitoring and review were not met.
Surveyors found that the generator annunciator panel, located behind the central nurses station, was not powered and appeared disconnected or disabled. This issue was confirmed by the Maintenance Director and acknowledged by facility leadership.
Surveyors found that the facility did not have documentation showing its Emergency Preparedness Program (EPP) was reviewed and updated annually, as required. Both the Administrator and Maintenance Director acknowledged the lack of annual review records during the survey.
The facility did not maintain the kitchen hood fire suppression system as required, failing to provide documentation for a semiannual inspection and leaving previously noted discrepancies uncorrected. This was confirmed by both the Administrator and Maintenance Director.
The facility did not ensure all fire alarm system devices, including duct detectors, were tested and maintained as required, and lacked documentation of biennial smoke detector sensitivity testing. Additionally, a smoke detector was found improperly placed near an HVAC supply vent. These issues were confirmed by facility leadership.
Surveyors found that the facility could not provide documentation of the required 5-year internal backflow inspection for the sprinkler system, and the fire backflow device was observed to be 'Red Tagged' and inoperable. These deficiencies were confirmed by facility leadership.
The facility did not provide documentation of annual inspections or evidence of a trained, certified individual responsible for fire and smoke door assemblies, as required by NFPA standards. This deficiency was confirmed by facility leadership during interviews and record review.
The facility did not maintain required documentation for the emergency generator engine and failed to perform annual diesel fuel testing as required by NFPA standards. These deficiencies were confirmed by the Maintenance Director and acknowledged by facility leadership.
The facility did not provide adequate documentation for the four-year fire and smoke damper inspection, as required by NFPA 80, with vendor records lacking details on the number, locations, and type of dampers. This deficiency was acknowledged by facility leadership.
Failure to Provide Proper Wound Care and Medication Management
Penalty
Summary
The facility failed to provide appropriate care and treatment for multiple residents, as evidenced by observations, interviews, and record reviews. For one resident with multiple abdominal and limb dressings, there were inconsistencies and omissions in wound care documentation and execution. The resident reported that dressings were last changed several days prior, and staff were unaware of all wound sites. Physician orders for wound care were not consistently followed, and some dressings lacked required labeling with date and initials. Staff interviews revealed a lack of clarity regarding responsibility for wound care on weekends and incomplete skin assessments upon admission. Another resident was observed with a dressing on her limb that had a dried dark substance and was missing date and initials, contrary to facility policy and physician orders. The resident stated the dressing was due to an injury, but the required documentation and proper dressing maintenance were not evident during multiple observations. The Director of Nursing confirmed that all dressings should be dated and initialed, which was not done in this case. Additionally, a third resident's medication was held by nursing staff without appropriate parameters or physician clarification, as indicated by the Medication Administration Record and staff interviews. The DON acknowledged that the medication was held without proper orders, and the facility's policy requires medications to be administered according to prescriber orders and standards of practice. These findings demonstrate failures in following professional standards, care plans, and physician orders for both wound care and medication management.
Infection Control Deficiencies in Equipment Handling, PPE Use, and Hand Hygiene
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control practices. Staff failed to properly store respiratory equipment, such as passive masks and tubing, for several residents. In multiple instances, these items were left unbagged on surfaces or on the floor, contrary to facility policy and staff expectations that such equipment should be bagged when not in use. Additionally, disposable equipment was not consistently labeled or changed as required. Staff did not consistently adhere to enhanced barrier precautions (EBP) for residents with medical devices or those requiring such precautions. Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) were observed providing direct care, including dressing, toileting, and medication administration, to residents on EBP without wearing the required gowns, and in some cases, staff were unaware that residents were on EBP. The Director of Nursing (DON) confirmed that staff are expected to wear both gloves and gowns when providing care to residents under EBP, and that some residents who met criteria for EBP did not have appropriate orders in place. Hand hygiene and equipment cleaning protocols were not followed during resident care and medication administration. Staff were observed changing gloves multiple times without performing hand hygiene in between, despite facility policy and DON statements that hand hygiene is required between glove changes. Medical equipment, such as blood pressure cuffs and pulse oximeters, was used on multiple residents without cleaning between uses. Additionally, staff handled oral medications with bare hands and administered medications that had dropped onto unclean surfaces. These actions were inconsistent with facility policies and accepted standards for infection prevention and control.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents. For one resident, the MDS inaccurately documented that the resident had adequate vision without corrective lenses, despite both the resident's son and a registered nurse confirming the resident's vision was impaired and required corrective lenses. The optometry evaluation also indicated the use of corrective lenses, and the MDS Coordinator acknowledged the inaccuracy in the assessment. Another resident was reported to be using a tube for medication administration, but the MDS assessment did not reflect the presence of the tube or any related nutritional approaches. The MDS Coordinator confirmed this was incorrect. Additionally, a third resident, who was on a mechanical soft diet due to a broken dental appliance, was not accurately represented in the MDS under the oral/dental status section. The resident expressed frustration about not having the dental appliance, and the MDS Coordinator admitted the annual assessment was marked incorrectly.
Failure to Complete Accurate PASRR Assessment for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) was completed for one resident who was reviewed for unnecessary medications. The resident was admitted with diagnoses including major depressive disorder and other mental health conditions. The Level I PASRR for this resident listed certain mental illnesses but omitted others, despite documentation in the hospital discharge summary and the Minimum Data Set (MDS) assessment indicating additional relevant diagnoses. The facility's policy requires that all individuals being admitted have a completed PASRR Level I prior to admission, and that the PASRR be reviewed for accuracy and corrected if necessary. During an interview, the Administrator acknowledged that the facility did not follow its process to review and correct the PASRR upon the resident's admission from the hospital. The resident's medical records, including a visit note and hospital discharge summary, documented a history of multiple mental health conditions that were not fully reflected in the PASRR. This failure to ensure an accurate PASRR assessment resulted in noncompliance with federal requirements for preadmission screening for individuals with mental illness or intellectual disability.
Failure to Develop and Implement Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents as required by federal regulations. For one resident with diagnoses including generalized anxiety and post-traumatic stress disorder, the care plan did not include a focus or interventions addressing these mental health conditions, despite physician orders and clinical notes indicating the need for monitoring and documentation of related symptoms. Staff interviews confirmed that these diagnoses and their associated care needs were not incorporated into the resident's care plan and needed to be added. For another resident, physician orders and clinical documentation indicated the need for enhanced barrier precautions due to a medical device and wound care requirements. However, the resident's care plan did not address enhanced barrier precautions, and staff interviews, including those with the LPN Unit Manager, DON, and MDS Coordinator, confirmed that this omission was inconsistent with facility expectations and policy. The facility's policy requires the identification of problem areas and the development of targeted interventions, which was not followed in these cases.
Failure to Implement Physician-Agreed Pharmacy Recommendation
Penalty
Summary
The facility failed to ensure that a physician-agreed medication regimen recommendation from the consultant pharmacist was implemented for one resident. The consultant pharmacist recommended that the resident receive vitamin D3, 1000 IU once daily, based on clinical guidelines for elderly individuals to maintain bone health. The attending physician reviewed this recommendation and documented agreement with the plan, indicating, "Agree; will do." However, a review of the resident's current physician orders revealed that no order for vitamin D3 had been entered. Interviews with facility staff, including the DON and a nurse practitioner, confirmed that the process for addressing pharmacy recommendations involves unit managers and the ADON updating the electronic medical record when a provider agrees to a recommendation. Despite this expectation, the agreed-upon order was not entered. The facility's policy requires that drug regimen review recommendations be acted upon, but in this case, the necessary follow-through did not occur, resulting in the deficiency.
Failure to Address Pharmacist's Recommendation for Unnecessary Drug
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary drugs, as required by federal regulations. Specifically, the consultant pharmacist identified that the resident was receiving a long-acting medication without a stop date and recommended evaluating the current need and considering adding a stop date. The physician initially agreed to discontinue the medication but later disagreed, stating the medication was to be given as needed (PRN). Despite these recommendations and responses, the resident continued to receive the extended-release medication twice daily, as documented in the Medication Administration Records over an extended period. Interviews with facility staff, including the DON and a Nurse Practitioner, revealed that the process for addressing consultant pharmacist recommendations involved dividing the recommendations among unit managers and the ADON, with the expectation that any provider orders should be updated in the electronic medical record. The facility's policy required that drug regimen reviews be conducted monthly and that any irregularities be reported and acted upon, with documentation of the physician's review and actions taken. However, the records showed that the recommendations regarding the medication were not properly addressed or documented, resulting in the continued administration of the medication without adequate justification or a stop date.
Improper Storage and Unauthorized Access to Medications
Penalty
Summary
Surveyors observed multiple instances where drugs and biologicals were not stored in accordance with professional standards and facility policy. In one case, a resident had a bottle of spray at their bedside, which the resident reported using at night. Staff confirmed that residents are not permitted to self-administer medications without an evaluation, care plan, and physician order, none of which were in place for this resident. Another resident had a bottle of lubricant and powder on their bedside table and air conditioning unit, stating that they used these items as needed, sometimes with nurse assistance. A third resident had a tube of an unidentified substance at their bedside, which staff confirmed was not ordered and was brought in by family without staff knowledge or approval. In each case, staff acknowledged that the residents were not authorized to self-administer medications and that such items should not be accessible without proper assessment and documentation. Additionally, a medication cup containing a white pill was found unattended in a resident's room. The resident was unaware of the medication's purpose, and the LPN stated they believed the resident had already taken all medications. The DON confirmed that no residents in the facility were authorized to self-administer medications and that medications should not be left unattended in resident rooms. Facility policies reviewed by surveyors required that medications be stored securely and that self-administration only occur following interdisciplinary assessment and physician order, which was not followed in these instances.
Failure to Provide Timely Dental Services for Lost Dentures
Penalty
Summary
The facility failed to ensure that a resident received necessary dental services, specifically the replacement of lost or damaged dentures. The resident reported being on a mechanical soft diet solely due to the absence of dentures, expressing dissatisfaction with the inability to eat properly. Interviews with facility staff revealed that the process for obtaining dental services was delayed due to insurance requirements and the need for a referral from the resident's primary office to a dental clinic. Documentation in the medical record indicated that dental referrals were sent and that attempts were made to locate the resident's dentures for evaluation, but the dentures were not found, and the resident remained without them. Further review of the resident's records showed that dental consultations noted the absence of dentures and the resident's interest in obtaining a new set. Staff documented that the resident was able to obtain adequate nutrition and was not experiencing discomfort, but the only reason for the mechanical soft diet was the lack of dentures. The facility's policy required referral for dental services within three days of loss or damage of dentures, or documentation of actions taken and reasons for delay, but the report indicates ongoing delays and lack of resolution for the resident's dental needs.
Failure to Label and Date Stored Food Items
Penalty
Summary
Surveyors observed that the facility failed to ensure proper food storage practices in both the kitchen walk-in freezer and the nourishment room refrigerator. During an initial kitchen tour with the Dietary Manager, a plastic see-through bag containing unidentified food items was found in the walk-in freezer without any label or date. The Dietary Manager confirmed that the item should have been labeled and dated, in accordance with the facility's food storage policy, which requires all frozen foods to be covered, labeled, and dated. Additionally, in the nourishment room refrigerator on Desota Hall, a bag containing wrapped crackers and a bowl of covered food were found without dates. The Dietary Manager again acknowledged that these items should have been dated. The facility's policy for foods brought in by family or visitors also requires perishable foods to be stored in resealable containers with tight-fitting lids, labeled with the resident's name, item name, and a use-by date, with nursing staff responsible for discarding perishable foods on or before the use-by date. These observations indicate that the facility did not follow its own policies and professional standards for food service safety regarding labeling and dating stored food items.
Failure to Provide Required Specialized Rehabilitative Services After Program Discontinuation
Penalty
Summary
The facility failed to provide or obtain specialized rehabilitative services as required for one resident who was previously participating in a restorative program. The resident reported that after the facility discontinued the restorative program, no further rehabilitative services or evaluations were provided, despite active physician orders for evaluation and treatment. The resident's care plan indicated a need for a functional maintenance program due to self-care performance issues following an infraction affecting the left dominant side, but no current interventions were implemented after the program was discontinued. Interviews with facility staff, including the Functional Maintenance Coordinator, DON, and Rehabilitation Director, confirmed that the restorative program was ended and replaced with a functional maintenance program. However, the resident in question was not evaluated or included in the new program, and quarterly assessments were not conducted as required. Staff acknowledged that there was no process in place to ensure continuity of care for residents transitioning from the discontinued program, and the lack of evaluation was attributed to oversight or human error.
Deficient Medical Record Documentation and Incomplete Medication and Wound Care Records
Penalty
Summary
Surveyors identified multiple deficiencies related to the maintenance of complete and accurate medical records for several residents. For one resident with behavioral monitoring orders, staff failed to document required observations as specified by the physician, instead marking an 'X' rather than indicating 'yes' or 'no' for the presence of behaviors, and did not provide corresponding progress notes when behaviors were observed. The Director of Nursing confirmed that the documentation was incomplete and did not follow the order's requirements. For two residents receiving medication management, there were errors in both the transcription and documentation of medication orders and administration. One resident's medication order was transcribed incorrectly, using the wrong symbol for a critical parameter, which was acknowledged by both the DON and an Advanced Practice Registered Nurse. Another resident had insulin doses held due to low blood sugar readings, but staff failed to document provider notification or the rationale for withholding the medication in the nurses' notes, as required by facility policy and standard practice. Additionally, for a resident requiring daily wound care, staff documented that care was provided on days when it was actually performed by another nurse, without verifying completion. The responsible nurse admitted to documenting care based on verbal reports rather than direct observation or confirmation, and a unit manager confirmed that documenting care not personally completed constitutes false documentation. Facility policy requires detailed documentation of wound care, including date, time, and wound appearance, which was not consistently followed.
Failure to Maintain Effective QAPI Program for Weight Loss Monitoring
Penalty
Summary
The facility failed to maintain an effective, data-driven Quality Assurance and Performance Improvement (QAPI) program as required by federal regulations. Specifically, the facility did not provide evidence of ongoing monitoring and documentation for a performance improvement plan (PIP) related to weight loss among residents. The QAPI program was expected to include systematic identification, reporting, investigation, analysis, and prevention of adverse events, as well as documentation of corrective actions and performance improvement activities. However, the facility was unable to demonstrate that these processes were consistently followed for residents experiencing significant weight loss. A review of the facility's Loss Performance Improvement Plan indicated that residents who experienced significant weight loss were to be reviewed weekly in risk meetings until their weight stabilized for four weeks. The plan also required appropriate notifications, Registered Dietitian consults, care plan updates, and consistent weighing practices. Despite these outlined procedures, documentation revealed that two residents identified for monitoring were not weighed according to the prescribed weekly schedule, and there was no proof of weekly risk meetings or adequate monitoring as required by the plan. During interviews, the Director of Nursing (DON) acknowledged the lack of a set plan for transitioning from restorative to a Functional Maintenance Program and admitted that documentation for weekly monitoring and meetings was not available. The facility's QAPI policy required identifying issues, developing and implementing corrective actions, and reviewing and analyzing data, but the facility was unable to provide evidence that these steps were followed for the residents in question.
Failure to Implement Effective Antimicrobial Stewardship Program
Penalty
Summary
The facility failed to establish and implement an effective stewardship program to monitor the use of antimicrobials for two residents. For one resident, a physician ordered a preventative antimicrobial regimen without documented consideration of a 'time out' or pause to reassess the need for continued therapy. The Advanced Practice Registered Nurse (APRN) admitted to not having considered a time out and was unable to provide documentation of the clinical assessment that led to the order, citing issues with transitioning records. The Assistant Director of Nursing (ADON) also could not provide documentation of discussions with providers regarding antimicrobial use. For another resident, antimicrobials were ordered without any diagnostic testing to confirm the need for such treatment. The Director of Nursing (DON) confirmed that no test was ordered and that the provider prescribed the medication without testing. Staff interviews revealed that a physician frequently prescribed antimicrobials based on symptoms alone, such as coughing, without ordering diagnostic tests, and that staff felt unable to discontinue these medications once the provider had spoken to the resident. Review of the facility's stewardship policy indicated that regular review of antimicrobial utilization and laboratory reports was required, but these practices were not followed in the cases reviewed.
Generator Annunciator Panel Found Disconnected
Penalty
Summary
During a facility tour, surveyors observed that the generator annunciator panel, which is required to be powered and located in a place readily observed by operating personnel, was found to have no power. The panel was located on the wall behind the central nurses station near the central hallway. Testing of the annunciator revealed it was disconnected or disabled, and this was confirmed by the Maintenance Director during the tour. The deficiency was acknowledged by both the Administrator and the Maintenance Director during the exit conference. No information regarding residents or their medical conditions was included in the report.
Failure to Annually Review and Update Emergency Preparedness Program
Penalty
Summary
The facility failed to review and update its Emergency Preparedness Program (EPP) as required by federal regulations. During a record review with the Administrator and the Maintenance Director, surveyors found that there was no documented evidence showing the EPP had been reviewed and updated annually. This deficiency was identified during the survey process when the facility was unable to provide records demonstrating compliance with the annual review and update requirement for the EPP. Both the Administrator and the Maintenance Director acknowledged the absence of documentation regarding the annual review and update of the EPP during the exit conference. The Maintenance Director also concurred with the findings during the interview. No information was provided in the report regarding specific residents or their conditions at the time of the deficiency.
Failure to Maintain Kitchen Hood Fire Suppression System
Penalty
Summary
The facility failed to maintain the kitchen hood cooking fire suppression system in accordance with required inspection and maintenance protocols. During a record review with the Administrator and Maintenance Director, it was found that the facility could not provide documentation for one of the required semiannual maintenance inspections. The last available semiannual inspection, dated 7/29/24, indicated discrepancies that had not been corrected, and this was confirmed during the facility tour. Both the Administrator and Maintenance Director acknowledged these findings during the exit conference. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Fire Alarm System Testing and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with NFPA 72 standards. During a record review with the Administrator and Maintenance Director, it was found that not all fire alarm devices had been tested, inspected, and maintained as required. Specifically, 5 out of 12 duct detector devices were missed during testing and were reported as not accessible by the fire alarm vendor. Additionally, the facility could not provide documentation showing that biennial sensitivity testing of smoke detectors had been conducted, with no records available to indicate when the last such testing occurred. During a facility tour, a smoke detector was observed to be within 36 inches of an HVAC supply vent in the main service hallway, which does not comply with placement requirements. These deficiencies were acknowledged by both the Administrator and the Maintenance Director during the exit conference. No information about specific residents or their conditions was provided in relation to these deficiencies.
Failure to Maintain Sprinkler System and Provide Required Inspection Documentation
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 101 requirements. During a record review with the Administrator and Maintenance Director, the facility was unable to provide documentation of the required 5-year internal backflow inspection report. Additionally, during a facility tour, surveyors observed that the fire backflow device located at the main entrance was 'Red Tagged,' indicating that the system was in failure and inoperable. These findings were confirmed by the Maintenance Director during the interview and acknowledged by both the Administrator and Maintenance Director at the exit conference. No information about residents or their medical conditions was included in the report.
Failure to Maintain and Inspect Fire and Smoke Door Assemblies
Penalty
Summary
The facility failed to provide regular inspections, testing, and maintenance of fire and smoke door assemblies as required by NFPA 80 and NFPA 105. During a record review with the Administrator and Maintenance Director, the facility was unable to produce documentation of annual inspections for smoke doors or evidence of training for a competent, certified individual responsible for fire and smoke doors. This lack of documentation and training was confirmed during interviews with facility leadership. The deficiency was acknowledged by both the Administrator and the Maintenance Director during the exit conference. No information was provided regarding specific residents or patient conditions related to this deficiency. The report focuses solely on the absence of required inspection records and training for fire and smoke door assemblies.
Failure to Maintain Emergency Power System and Annual Diesel Fuel Testing
Penalty
Summary
The facility failed to maintain its Emergency Power System (EPS) in accordance with NFPA 80 and NFPA 110 requirements. During a record review with the Administrator and Maintenance Director, it was found that the emergency generator engine manufacturer's recommendations were not available for reference. Additionally, the facility did not conduct the required annual testing of the generator's diesel fuel as specified by the relevant codes. These deficiencies were confirmed during interviews with the Maintenance Director, who concurred with the findings. The lack of documentation and failure to perform the mandated fuel testing were acknowledged by both the Administrator and Maintenance Director during the exit conference. No information about residents or their conditions was provided in the report.
Failure to Document Fire and Smoke Damper Inspections per NFPA Standards
Penalty
Summary
The facility failed to maintain proper documentation for the four-year fire and smoke damper inspection, testing, and maintenance as required by NFPA 80. During a record review with the Administrator and Maintenance Director, it was found that the vendor documentation only indicated that the fire and smoke dampers were functioning, but did not specify the number of dampers, their locations, or the type of system installed. This lack of detailed documentation meant the facility could not demonstrate compliance with the required standards for maintaining the integrity of the fire alarm system to ensure proper alarm and safe relocation of residents, staff, or other building occupants in the event of a fire. These findings were confirmed by both the Administrator and the Maintenance Director during the exit conference.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
