Lake Haven Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dunedin, Florida.
- Location
- 1351 San Christopher Dr, Dunedin, Florida 34698
- CMS Provider Number
- 105350
- Inspections on file
- 21
- Latest survey
- October 13, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Lake Haven Nursing And Rehab Center during CMS and state inspections, most recent first.
Two residents with complex medical conditions did not receive weekly skin checks as required by physician orders and care plans. Documentation in the EMR was incomplete, and staff interviews revealed a lack of consistent scheduling and follow-through for skin assessments. The facility's policy for weekly skin evaluations by licensed nurses was not adhered to, resulting in a deficiency in care.
Three residents with significant wounds and pressure ulcers did not receive timely or consistent wound care as ordered by physicians. Documentation showed delays in obtaining and implementing wound care orders, incomplete treatment records, and lack of wound care for some wounds. Nursing staff and the DON confirmed that required admission assessments and prompt physician notification for wound care were not consistently performed.
A resident's Nursing Admission Screening/History was left incomplete and blank at the time of admission, with essential assessment sections missing. Over a month after the resident's discharge, an LPN completed and locked the assessment at the request of the CNO, despite not having performed the original admission. The CNO confirmed this was not appropriate and that the facility lacked a specific policy for admission documentation.
Two residents in an LTC facility did not receive therapeutic diets as ordered by their physicians. One resident, at risk for aspiration, was given a mechanical soft diet instead of the required pureed diet due to a missing dietary change form. Another resident, who needed double portions for weight management, did not receive the correct meal portions. The facility lacked a policy for following meal tickets, leading to these deficiencies.
Two residents in a facility did not receive their prescribed therapeutic diets, leading to deficiencies in dietary services. One resident, requiring a pureed diet and double protein portions, was given a mechanical soft diet due to staff's lack of awareness of dietary changes. Another resident, needing double protein portions, received only a single portion despite the meal ticket indicating otherwise. The facility lacked a policy for ensuring dietary orders were followed, resulting in residents not receiving appropriate nutrition.
A CNA was witnessed abusing two residents, slapping them during care. The incident was not reported immediately due to fear, leaving other residents at risk. Both residents were non-verbal and dependent on staff for care. The facility's abuse prevention policy was not followed, leading to a failure to protect vulnerable residents.
A facility failed to report an incident of abuse by a CNA towards two residents in a timely manner. The residents, who were non-verbal and highly dependent on staff, were physically abused by the CNA, leaving a handprint on one. The incident was not reported immediately due to fear of retaliation, and the facility's policy for immediate reporting was not followed, leading to a significant deficiency.
The facility failed to maintain an effective infection prevention and control program, with deficiencies including not reporting rashes to the health department, not changing a blood-stained pillowcase for a resident with a bloodborne pathogen, and not sanitizing a glucometer after use. The DON/IP was unaware of scabies treatment for residents, and infection control protocols were not followed during medication administration.
The facility failed to maintain a clean and safe environment, with observations of unsanitary conditions in resident rooms, bathrooms, and common areas. Issues included petrified worms, brown and black stains, debris accumulation, and exposed wires on bed remotes. Interviews with the Maintenance Director and Nursing Home Administrator confirmed the deficiencies, highlighting a failure to adhere to cleaning policies. Photographic evidence supported the findings, indicating a systemic issue affecting multiple areas.
The facility failed to ensure accurate accountability and storage of controlled medications in two medication carts. Discrepancies were found in the narcotic count, including loose pills and incorrect records for Clonazepam, Oxycodone, Tramadol, and Hydrocodone/APAP tablets. A card for a discharged resident was also found. An LPN admitted to not signing out medications due to a hectic morning, and the DON was unaware of the issue, indicating a failure to follow facility policies on controlled substances and medication storage.
A facility reported a 28.57% medication error rate, with errors including incorrect dosages and improper medication handling. An LPN administered incorrect doses via a G-tube, and an RN crushed extended-release medications, mixing them with pudding. Another LPN failed to prime an insulin pen before use. Interviews confirmed these practices did not align with guidelines.
The facility failed to provide a dignified dining experience for three residents during assisted dining. A CNA was observed standing while assisting a resident with amyotrophic lateral sclerosis, despite a chair being available. Another CNA stood while feeding a resident and later sat on a resident's bed, citing a lack of chairs. The facility's policy emphasizes a dignified existence, which was not upheld.
A resident with a moderately impaired mental status was moved to a new room without prior notice or explanation. The facility failed to document the room change or communicate the reason to the resident, contrary to its policy requiring advance notice and documentation.
A resident with a shoulder wound did not receive wound care as per physician orders, resulting in missed treatments and lack of documentation. The resident's care plan did not address the wound, and staff confirmed the absence of documented treatments. The facility's policy required treatment per physician order, which was not followed.
The facility failed to properly store respiratory equipment for two residents, leading to unsanitary conditions. One resident's oxygen tubing was found on the floor, while another's tubing had not been changed as per physician orders. Staff interviews revealed a lack of understanding and absence of a policy for storing respiratory equipment.
The facility failed to properly store and secure medications, with unlocked cabinets and carts containing resident medications, unlabeled insulin pens, and loose pills. The DON struggled to secure the narcotic box due to key access issues, and medication carts were left unattended, violating facility policy.
A resident with amyotrophic lateral sclerosis, who was cognitively intact, was served green beans and spicy sausage despite documented dislikes. The CNA did not check the meal ticket for dislikes, and the resident was not offered an alternative. The CDM, DON, and NHA acknowledged the failure to follow the process for honoring meal preferences.
A facility failed to ensure hospice services were provided according to professional standards due to poor communication and documentation for a resident with advanced dementia. Despite a physician order for hospice care, there was no documentation in the resident's progress notes or care plan. Interviews revealed communication issues between facility staff and the hospice provider, with the DON noting a lack of documentation from the hospice nurse.
Failure to Complete and Document Weekly Skin Checks for Two Residents
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, specifically regarding the completion of weekly skin checks for two residents. For one resident with multiple diagnoses including vascular dementia, chronic kidney disease, and diabetes, physician orders required weekly skin checks. However, review of the electronic medical record revealed only one documented skin evaluation during the resident's stay, despite the presence of scratches and dried blood on the arms. Additionally, there was no care plan addressing skin integrity or weekly skin checks for this resident. Interviews with nursing staff and the acting DON confirmed that weekly skin checks were not performed or documented as required. For another resident with diagnoses such as osteomyelitis, hepatitis B, and septic pulmonary embolism, the care plan included weekly skin checks due to impaired or at-risk skin integrity. Despite this, the medical record showed only one skin evaluation, and there was no evidence of a weekly skin assessment schedule or documentation of skin checks for this resident. Staff interviews revealed that the unit did not have a weekly skin assessment schedule in place, and the DON acknowledged the missing assessment, stating that a provider's note was being counted as a skin assessment, although this did not meet the facility's policy requirements. The facility's policy required licensed nurses to complete and document weekly skin evaluations for all residents. Observations, interviews, and record reviews demonstrated that this policy was not consistently followed, resulting in a failure to provide care and treatment according to physician orders, resident care plans, and professional standards of practice for the two residents involved.
Failure to Provide Timely and Consistent Wound Care per Physician Orders
Penalty
Summary
The facility failed to provide appropriate wound care treatment and follow physician orders for three residents who were admitted with significant skin and wound care needs. For one resident, the admission records and physician documentation indicated multiple skin tears and wounds requiring specific dressing changes and wound care regimens. However, the treatment administration record showed that wound care orders were not implemented upon admission, and wound care was only documented once during the resident's stay. The resident's responsible party also reported that wound care was not provided consistently. Another resident was admitted with multiple pressure ulcers and wounds, including stage IV pressure areas and an unstageable wound. Physician orders and wound care consults were documented, specifying daily wound care treatments for several sites. Despite this, the facility's records lacked documentation of wound care being provided until several days after admission, and initial orders did not cover all identified wounds. The nursing admission assessment confirmed the presence of multiple wounds, but corresponding treatment orders were incomplete or delayed. A third resident was admitted for wound care with several unstageable pressure ulcers documented on admission forms and nursing assessments. Despite the clear need for wound care, the facility's records did not contain any wound care orders for this resident. Interviews with nursing staff and the Director of Nursing confirmed that the facility's policy required prompt skin assessments and obtaining physician orders for treatment upon admission, but this process was not followed for these residents. The Director of Nursing acknowledged that the facility's expectations for wound care assessment and treatment were not met in these cases.
Incomplete and Late Documentation of Admission Assessment
Penalty
Summary
The facility failed to ensure that medical records were completed and accurate for one resident out of three sampled. Upon review, the Nursing Admission Screening/History for a resident admitted from the hospital and later discharged was found to be blank except for auto-populated vital signs. Key sections such as admission details, neurological status, social history, physical assessments, and medication information were not documented at the time of admission. The assessment remained incomplete and unlocked in the electronic medical record system until more than a month after the resident's discharge. On the day of the survey, a staff LPN/Unit Manager completed and locked the previously blank assessment at the request of the Chief Nursing Officer (CNO) to print the document. The LPN admitted to filling out the assessment despite not having performed the original admission, and the CNO confirmed that this was not appropriate practice. The CNO also acknowledged that the facility did not have a specific policy for documentation of admission assessments, and that documentation should have been completed within 72 hours of admission, not after discharge.
Failure to Provide Therapeutic Diets as Ordered
Penalty
Summary
The facility failed to provide a therapeutic diet according to physician orders for two residents, leading to deficiencies in their care. Resident #1, who was admitted with medical diagnoses including cerebral infarction and dysphagia, was observed not receiving the appropriate pureed diet and thickened liquids as ordered. Despite the speech therapist's recommendation to downgrade his diet to pureed due to aspiration risk, the dietary manager was unaware of the change, resulting in Resident #1 receiving a mechanical soft diet instead. This miscommunication was attributed to a missing dietary change form, which was not properly processed in the dietary system. Resident #25, who was supposed to receive double portions of protein due to weight loss, did not receive the correct meal portions as per his dietary orders. During a lunch observation, it was noted that he received only one Salisbury steak patty instead of the double portion indicated on his meal ticket. The facility's Registered Dietician confirmed the oversight and acknowledged that the meal ticket was not followed, which should have been caught by the tray line staff. The lack of adherence to the meal ticket resulted in Resident #25 not receiving the necessary nutritional support to address his weight loss. The facility's dietary management process was found to be lacking, as there was no policy or procedure in place for following and honoring meal tickets and diets. The dietary staff, including the cook and dietary aide, were unable to explain how the errors occurred, indicating a systemic issue in the meal service process. The absence of a structured protocol for ensuring dietary orders are accurately followed contributed to the deficiencies observed in the care of both residents.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Identified resident #1: Resident was provided an additional serving of protein during lunch meal service per physician order. Diet orders were reviewed by the Chief Nursing Officer. Tray ticket updated with Puree diet per physician order and Speech recommendations. Resident did not suffer any adverse effects from not receiving the proper diet texture. Resident #1 was assessed by the APRN. APRN progress notes documented: CTA. No chills or increased in decrease in SPO2 noted. No. Identified resident #25 was provided an additional serving of protein per physician order during lunch meal service (205). (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quality review completed by Certified Dietary Manager/designee to ensure the residents receive meals per physician order, tray tickets match the physician order and residents receive double portions/2x entrees. Quality review completed by the DON/designee ensuring residents are provided with snacks when requested to be completed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Dietary staff re-educated by the Certified Dietary Manager on the components of this regulation and that residents receive meals per physician order, tray tickets match the physician order, tray line validates what is served match the tray ticket and residents receive double portions/2x entrees. When the Dietary Manager is not present, the dietary staff will update the sheet located in the kitchen to document new admissions, re-admissions or diet changes and update the pre-printed tickets with changes, write a ticket with new admissions/re-admissions for the Dietary Manager to input in the tray card system upon return to the center completed. Current Certified Nursing Assistants re-educated by the DON/designee regarding ensuring residents receive snacks upon request to be completed. (4) 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; Certified Dietary Manager/designee to conduct ongoing quality monitoring through visual observation of the tray line and meal service in the dining room to ensure residents are provided meals per physician order 5 x weekly x 4 weeks, 3 x weekly x 4 weeks, twice weekly x 4 weeks then weekly and PRN as indicated. DON/designee to conduct ongoing quality monitoring through resident interview and observation to ensure snacks are provided upon request 3 x weekly x 2 weeks, twice weekly x 2 weeks then weekly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months then quarterly and PRN as indicated and modified based on findings.
Failure to Provide Therapeutic Diets as Prescribed
Penalty
Summary
The facility failed to provide therapeutic diets according to physician orders for two residents, leading to deficiencies in dietary services. Resident #1, who was admitted with medical diagnoses requiring a specific diet, did not receive the prescribed pureed texture and double portion protein/entrée at each meal. During an observation, Resident #1 was given a mechanical soft diet instead of the required pureed diet, and staff were unaware of the resident's dietary needs. The Dietary Manager was not informed of the diet change, resulting in the resident receiving incorrect meal portions. Resident #25 also did not receive the prescribed double portions of protein as indicated in the physician's orders. Despite the meal ticket specifying double portions, the resident received only one patty of Salisbury steak instead of two. The Registered Dietician confirmed that the resident should have received double portions due to previous weight loss and the need for increased nutritional intake. The facility's dietary staff failed to follow the meal ticket instructions, leading to the resident not receiving the necessary dietary support. The facility lacked a policy and procedure for following and honoring meal tickets and diets, contributing to the oversight in providing the correct meals to residents. The dietary staff, including the Cook and Dietary Aide, were unable to explain how the error occurred, indicating a lack of communication and oversight in the dietary service process. The absence of a structured protocol for ensuring dietary orders are followed resulted in residents not receiving the appropriate nutrition as prescribed by their physicians.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Identified resident #1: Resident was provided an additional serving of protein during lunch meal service per physician order. Diet orders were reviewed by the Chief Nursing Officer. Tray ticket updated with Puree diet per physician order and Speech recommendations. Resident did not suffer any adverse effects from not receiving the proper diet texture. Resident #1 was assessed by the APRN. APRN progress notes documented: CTA. No chills or increase in or No decrease in SPO2 noted. Identified resident #25 was provided an additional serving of protein per physician order during lunch meal service. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review completed by Certified Dietary Manager/designee to ensure the residents receive meals per physician order, tray tickets match the physician order, and residents receive double portions/2x entrée. Quality review completed by the DON/designee r/t ensuring residents are provided with snacks when requested to be completed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Dietary staff re-educated by the Certified Dietary Manager on the components of this regulation and that residents receive meals per physician order, tray tickets match the physician order, tray line validates what is served match the tray ticket, and residents receive double portions/2x entrée. When the Dietary Manager is not present, the dietary staff will update the sheet located in the kitchen to document new admissions, re-admissions, or diet changes and update the pre-printed tickets with changes, write a ticket with new admissions/re-admissions for the Dietary Manager to input in the tray card system upon return to the center completed. Current Certified Nursing Assistants re-educated by the DON/designee r/t ensuring residents receive snacks upon request to be completed. (4) 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: Certified Dietary Manager/designee to conduct ongoing quality monitoring through visual observation of the tray line and meal service in the dining room to ensure residents are provided meals per physician order 5 x weekly x 4 weeks, 3 x weekly x 4 weeks, twice weekly x 4 weeks then weekly and PRN as indicated. DON/designee to conduct ongoing quality monitoring through resident interview and observation to ensure snacks are provided upon request 3 x weekly x 2 weeks, twice weekly x 2 weeks then weekly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months then quarterly and PRN as indicated and modified based on findings.
Failure to Protect Residents from Abuse by CNA
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse by a staff member, Staff J, CNA, towards two residents, Resident #11 and Resident #12. On December 20, 2024, Staff J was witnessed by another CNA, Staff I, slapping the residents on their legs, sides, and buttocks during care. Despite witnessing the abuse, Staff I did not report the incident until three days later, leaving other residents at risk of further abuse. The delay in reporting was attributed to Staff I's fear of being targeted due to past personal trauma. Resident #11, who was admitted with severe intellectual disabilities, quadriplegia, epilepsy, legal blindness, scoliosis, and gastrostomy status, was non-verbal and dependent on staff for all care needs. Resident #12, with a history of traumatic brain injury, psychosis, and muscle weakness, was also non-verbal and required substantial assistance for mobility and hygiene. Both residents were placed on 15-minute checks following the delayed report of abuse, as indicated by a sign observed in the facility. Interviews with facility staff revealed a culture of fear and reluctance to report abuse, as evidenced by Staff K, Door Monitor, who had previously witnessed Staff J's abusive behavior but did not report it. The Nursing Home Administrator confirmed the incident and stated that Staff J was suspended and later terminated. The facility's abuse prevention policy, which mandates immediate reporting and thorough investigation of abuse, was not adhered to, resulting in a failure to protect vulnerable residents from harm.
Failure to Report Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an incident of verbal and physical abuse by a Certified Nursing Assistant (CNA) towards two residents. The incident involved Staff J, CNA, who was reported to have been rough and abusive while assisting with the care of two residents. Staff I, CNA, who was present during the incident, reported that Staff J slapped the residents multiple times, leaving a handprint on one of them. Despite witnessing the abuse, Staff I did not report the incident immediately due to fear of retaliation, and the incident was only reported to the Nursing Home Administrator (NHA) three days later. The residents involved in the incident had significant medical conditions and were highly dependent on staff for their care. One resident had severe intellectual disabilities, quadriplegia, and was legally blind, while the other had severe cognitive impairment and required substantial assistance for mobility and hygiene. Both residents were non-verbal, making them particularly vulnerable to abuse. The delay in reporting the incident meant that the abuse was not addressed promptly, potentially compromising the residents' safety and well-being. The facility's policy required immediate reporting of any suspected abuse to management, but this protocol was not followed. Staff I, CNA, initially attempted to inform a nurse but was unsuccessful and instead reported the incident to a door monitor, who corroborated the abusive behavior of Staff J. The NHA was eventually informed of the incident, and law enforcement and state agencies were notified. However, the delay in reporting and the failure to adhere to the facility's abuse reporting policy constituted a significant deficiency in the facility's operations.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue was the failure to report rashes affecting four residents to the local health department and to ensure appropriate testing for a possible contagious epidermal condition. The Director of Nursing/Infection Preventionist (DON/IP) was unaware that the residents were being treated with medication for scabies, and the facility did not track these cases on their infection map. The DON/IP admitted to not reporting the rashes because they were not classified as scabies, despite the residents receiving treatment for it. Another deficiency involved a resident with a bloodborne pathogen who had a blood-stained pillowcase that was not changed promptly. Observations revealed that the pillowcase remained stained with blood for an extended period, posing an infection control concern. Interviews with the Nursing Home Administrator (NHA), DON/IP, and staff confirmed that the blood-stained linen should have been changed immediately to prevent infection risks. Additionally, the facility did not adhere to infection control practices during medication administration. A Licensed Practical Nurse (LPN) was observed placing a glucometer back into the medication cart without cleaning or sanitizing it after use. The DON/IP confirmed that glucometers should be cleaned with bleach wipes after each use, but this protocol was not followed. These lapses in infection control practices highlight significant deficiencies in the facility's infection prevention and control program.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its residents, as evidenced by multiple observations of unsanitary conditions in resident rooms, bathrooms, and common areas. Observations revealed the presence of petrified worms and lizards, brown and black stains on floors and walls, and significant debris accumulation in various locations. Bathrooms were particularly affected, with brownish stains and buildup on toilets, sinks, and floors, as well as cracked and uncleanable surfaces. The presence of exposed wires on bed remotes further highlighted the unsafe conditions. Interviews with the Maintenance Director and Nursing Home Administrator confirmed the unsatisfactory state of cleanliness and safety in the facility. The Maintenance Director acknowledged the need for cleaning rather than just floor maintenance, while the Nursing Home Administrator admitted awareness of the need to replace non-cleanable surfaces and ensure daily cleaning of resident rooms. Despite having policies in place for cleaning procedures, the facility failed to adhere to these standards, resulting in the observed deficiencies. The report includes photographic evidence of the unsanitary conditions, reinforcing the findings. The facility's failure to provide a clean and safe environment compromised the residents' right to a homelike setting, as mandated by regulations. The observations spanned several days, indicating a systemic issue rather than isolated incidents, and involved multiple resident rooms, bathrooms, and common areas, underscoring the widespread nature of the problem.
Controlled Medication Discrepancies in Medication Carts
Penalty
Summary
The facility failed to ensure accurate accountability and storage of controlled medications in two out of three medication carts inspected. During an observation, discrepancies were found in the narcotic count of the East Wing Carts 1 and 2. Specifically, there was a loose pill in the narcotic box, and several discrepancies in the controlled substance records for Clonazepam, Oxycodone, Tramadol, and Hydrocodone/APAP tablets. Additionally, a card containing Tramadol tablets was found for a resident who had already been discharged, indicating a failure to remove discharged narcotics from the cart. Interviews with staff revealed that the LPN responsible for the medication carts admitted to not signing out medications when administered due to a hectic morning. The LPN also stated that discharged narcotics should have been removed, but this task was overseen by the DON, who was unaware of the narcotic medication card from a discharged resident. The facility's policies on controlled substances and medication storage require compliance with laws and regulations, including immediate documentation after administration and secure storage of medications, which were not adhered to in this instance.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 28.57% based on observations of medication administration. During the survey, 35 medication administration opportunities were observed, resulting in ten errors involving four residents. These errors included incorrect dosages, failure to follow proper medication administration procedures, and inappropriate handling of medications. One incident involved a Licensed Practical Nurse (LPN) administering medications to a resident with a gastric tube. The LPN dispensed 5 mL of Levetiracetam instead of the prescribed 10 mL and failed to administer Ferrous Sulfate and Calcium as ordered via the PEG-Tube. Another error was observed when a Registered Nurse (RN) failed to administer Thiamine HCl to a resident as per the medication administration record. Additionally, the RN crushed extended-release medications, which is contraindicated, and mixed them with pudding for another resident. Further errors were noted when an LPN did not prime an insulin pen before administering insulin to a resident, contrary to the manufacturer's instructions. Interviews with the Director of Nursing, Medical Director, and Pharmacist confirmed that the facility's practices did not align with proper medication administration guidelines, contributing to the high error rate.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for three residents during assisted dining. Resident #8, diagnosed with amyotrophic lateral sclerosis, required staff assistance with eating. On a specific day, a CNA was observed standing while assisting the resident with their meal, despite a chair being available in the room. The CNA acknowledged the oversight and mentioned having received education on the proper procedure, which involves sitting at eye level with the resident during meal assistance. Both the Director of Nursing and the Nursing Home Administrator confirmed that the expectation was for staff to sit at eye level when assisting residents with meals. Additionally, Resident #3 was observed being fed by a CNA who was standing, and Resident #27 was assisted by a CNA who initially stood and then sat on the resident's bed, which is against protocol. The CNA admitted to sitting on the bed and cited a lack of available chairs as the reason. The facility's policy on Resident Rights emphasizes the importance of a dignified existence and being treated with respect, which was not upheld in these instances.
Failure to Provide Written Notification for Room Change
Penalty
Summary
The facility failed to honor a resident's right to receive written notification for a room change before the change was made. Resident #51, who had a moderately impaired mental status with a BIMS score of 11, was moved from her original room to a new room without prior notice or explanation. The resident expressed confusion about the move, stating she was not given an opportunity to see the new room or understand the reason for the change. The facility's records showed no documentation regarding the move or the reason for the room change. Interviews with facility staff revealed a lack of communication and documentation regarding the room change. The Social Services Director stated that the process for a room change involves notifying the resident and their representative, but there was no documentation in the room change binder. The Director of Nursing admitted to moving the resident without informing her of the reason, as he was waiting for information from the Health Department. The facility's policy requires advance notice and documentation of room changes, which was not followed in this instance.
Failure to Provide Wound Care Per Physician Orders
Penalty
Summary
The facility failed to provide wound care according to physician orders for a resident with a wound on the right shoulder. Observations revealed blood stains on the resident's pillow, and the resident confirmed the stains were from her shoulder wound. The wound was described as red, raw, and bloody, and was open to the air. The resident had a history of chronic viral hepatitis C, anoxic brain damage, seizures, anxiety disorder, obsessive-compulsive disorder, and bipolar disorder, with a moderate cognitive impairment score. The facility's Treatment Administration Record (TAR) showed missed wound care treatments on several occasions, specifically on the 19th, 20th, and 23rd of the month. The care plan did not include any focus, goals, or interventions for the resident's shoulder wound. Interviews with staff, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), confirmed the absence of documented treatments and the lack of a current care plan addressing the wound. The facility's policy required treatment per physician order with documentation in the medical record, which was not followed. The attending physician expected the nurses to adhere to the wound care orders, and the wound physician recommended covering the wound with a hydrocolloid dressing. However, the facility did not consistently apply the dressing or document the care provided, leading to the deficiency.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure the proper storage of respiratory equipment for two residents, leading to unsanitary conditions. Resident #34's oxygen tubing was observed on her bedside table and the floor, not stored in a sanitary manner. The resident, who uses oxygen as needed due to morbid obesity, expressed a need for oxygen during the observation. The care plan for Resident #34 indicated the need for oxygen therapy related to obesity, with specific interventions for monitoring and documenting respiratory distress. Interviews with staff revealed that the tubing and cannula should be stored in a bag when not in use, but there was no policy in place regarding the storage of respiratory equipment. Resident #39 was observed with oxygen tubing connected to an oxygen concentrator, with a piece of tape dated 9/16/2024, indicating the tubing had not been changed as per the physician's order. The facility's policy required oxygen tubing to be changed weekly or as needed when soiled. Staff interviews confirmed the tubing change process was not clearly understood, contributing to the deficiency. The lack of adherence to the facility's policy and physician orders for changing and storing respiratory equipment resulted in unsanitary conditions for both residents.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and security of medications in several areas, including the East medication storage room, Reflection Hallway treatment cart, and multiple medication carts. During observations, a cabinet in the Reflection Hallway was found unlocked with a resident's prescribed medication inside. Staff D, LPN/UM, acknowledged the cabinet should be locked but could not explain why the medication was there. Additionally, a PPE storage bin outside resident rooms contained an open box of Hydrocortisone Acetate 1% Cream packets. In the East Wing medication storage room, the narcotic box inside the refrigerator was unlocked, and the Director of Nursing (DON) struggled to find the correct keys to secure it, revealing that only one nurse, who works infrequently, had access to the keys. Further observations revealed issues with medication carts. The East Cart 2 had two unlabeled insulin pens and a loose pill in the narcotic box. Staff H, LPN, confirmed these items should be labeled and the loose pill destroyed. The cart's surface was also found with a liquid and white powdered substance. In the [NAME] Wing, Staff I, RN, found loose pills in the medication cart's drawer, which were not supposed to be there. Additionally, East Cart 2 was left unlocked and unattended, with numerous staff and residents passing by, until the Nursing Home Administrator intervened. The facility's policy mandates that all drugs and biologicals be stored securely and that medication carts not be left unattended, which was not adhered to in these instances.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to honor meal preferences for a resident with a primary diagnosis of amyotrophic lateral sclerosis, who was on a regular diet with pureed texture and nectar/mild thick consistency. The resident, who was cognitively intact with a BIMS score of 13 out of 15, had a documented dislike for green beans. Despite this, the resident was served green beans during lunch, which was confirmed by both the resident and Staff A, a Certified Nursing Assistant (CNA). The resident also expressed a dislike for the spicy sausage served and was not offered an alternative meal option. Interviews with Staff A, the Certified Dietary Manager (CDM), the Director of Nursing (DON), and the Nursing Home Administrator (NHA) revealed a breakdown in the facility's process for honoring meal preferences. Staff A admitted to not checking the resident's meal ticket for dislikes and failing to offer an alternative. The CDM acknowledged that the process to identify disliked items was not followed, resulting in the resident being served an unwanted meal. Both the DON and NHA confirmed that the resident should have been offered an alternative meal, and the dietary staff should have adhered to the resident's documented meal preferences.
Lack of Communication and Documentation in Hospice Services
Penalty
Summary
The facility failed to ensure hospice services were provided in accordance with accepted professional standards and principles due to a lack of communication and documentation in the medical record for a resident. The resident, who was re-admitted with early onset Alzheimer's disease and other co-morbidities, had a physician order for hospice care due to advanced dementia. However, there was no documentation of hospice services in the resident's progress notes or care plan, despite the Minimum Data Set indicating hospice care was being given. Interviews with facility staff revealed communication issues between the facility and the hospice provider. The Registered Nurse stated that communication with hospice only occurred if there was a change in the resident's condition. The Director of Nursing (DON) mentioned that the hospice nurse did not check out with her or leave any notes, which was a consistent problem. The facility's policy required a coordinated plan of care with hospice, including communication and documentation, which was not followed in this case.
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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