Lake Placid Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Placid, Florida.
- Location
- 125 Tomoka Blvd S, Lake Placid, Florida 33852
- CMS Provider Number
- 105455
- Inspections on file
- 27
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Lake Placid Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, mood disorder, depression, and anxiety, and with severe cognitive impairment, was started on and had dose changes to psychotropic medications (Haldol and Depakote) without prior notification to or consent from the Health Care Surrogate (HCS). The HCS reported not being informed before these medications were implemented and was upset about the lack of communication. An LPN and the unit manager described a facility process requiring prior HCS notification, risk discussion, and a signed psychotropic consent form, but acknowledged that the resident received multiple doses of Depakote and a Haldol injection before any psychotropic consent form was signed. MAR and progress notes confirmed administration of these medications and later documentation of consent, while the DON confirmed that consent should have been obtained and that there was no documentation showing the family was notified before the psychotropic medications were initiated.
A resident with multiple chronic conditions experienced a decline in appetite, responsiveness, and continence over several days, which was observed and reported by a CNA but not promptly assessed by nursing staff. Despite family concerns and requests for evaluation, no timely assessment or vital signs were documented by LPNs or the DON. The resident was eventually sent to the hospital and admitted for sepsis and dehydration, with facility records showing gaps in monitoring, documentation, and adherence to care plan interventions.
Multiple residents did not receive meals that accommodated their documented allergies, intolerances, and dietary preferences. One resident with a vegetarian diet repeatedly received meat, resulting in emotional harm and discharge against medical advice. Another resident with a shellfish allergy was served shrimp, and two others did not receive correct meal portions or were served foods they could not tolerate. These failures were confirmed through observations, interviews, and record reviews, showing a breakdown in the facility's dietary service processes.
The facility did not ensure accurate and complete PASARR Level I and II screenings for multiple residents with diagnoses of serious mental illness or intellectual disability. Several residents were admitted with psychiatric and behavioral health conditions, but their PASARR documentation was incomplete, missing, or not updated to reflect their diagnoses, and required Level II evaluations were not conducted. The process for managing PASARRs was inconsistent, with gaps in staff access and oversight, resulting in noncompliance with regulatory requirements.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Staff failed to consistently perform hand hygiene between tasks such as passing meal trays, assisting residents, and handling garbage, and did not offer or assist residents with hand hygiene prior to meals. Several staff members had fingernails and hair styles not in compliance with facility policy and CDC guidelines, and one CNA used a personal cloth to wipe perspiration while continuing to assist with meal service without hand hygiene. Residents with moderate cognitive impairment were not offered hand hygiene before meals, and staff did not always follow hand hygiene protocols during medication administration and meal service.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
The facility did not consistently log or address grievances raised by residents and their representatives, including concerns about staff behavior, call light response times, and dietary services. Despite staff awareness of the grievance process, concerns were not documented or followed up on, and residents did not receive communication regarding the resolution of their issues, contrary to facility policy.
The facility did not ensure that two residents and their representatives received proper documentation and notification regarding transfer or discharge. For one resident with severe cognitive impairment and multiple mental health diagnoses, there was no record of notification or the required transfer/discharge notice when transferred to the hospital. For another resident with cardiac and vascular conditions, discharge documentation was incomplete and unsigned, and there was no evidence that the required notice or discharge information was provided.
Surveyors found multiple safety deficiencies, including an unsecured and hot steam table accessible to residents, restrooms without emergency call cords, and unlocked cabinets containing hazardous chemicals. Additionally, a resident with behavioral disturbances and a history of aggression was left unsupervised despite orders for 1:1 supervision. The DON and staff confirmed these lapses in safety and supervision.
Surveyors identified that the facility's medication administration practices resulted in a medication error rate of 5 percent or greater, exceeding the regulatory limit.
Surveyors found that medication carts and storage areas contained expired, undated, and loose medications, including unlabeled vials and open bottles without dates. Controlled substances were not properly secured, with narcotic boxes attached to removable shelves and emergency kits not affixed. CPR carts containing glucose gel were left unlocked, and medications were observed unsecured on carts and at residents' bedsides, even though no residents were approved for self-administration. Staff interviews confirmed these lapses despite facility policies requiring secure and proper medication storage.
Residents on one unit did not receive their meal trays at the same time, resulting in some watching others eat or waiting extended periods for their food. One resident consumed another's drink and ice cream while unsupervised, and another remained at the table with a dirty tray long after the meal. Staff interviews revealed a lack of training on serving meals together, and a nurse administered eye drops at the dining table, all of which failed to uphold resident dignity.
A resident was not adequately prepared for a safe transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences, resulting in a deficiency in care planning and transition.
Three residents did not receive adequate assistance with ADLs, including grooming, nail care, haircuts, and shaving. One resident had matted hair and overgrown nails, another was unable to get a haircut due to the absence of a beautician, and a third had unaddressed facial hair and inconsistent shaving assistance. Staff interviews and documentation revealed lapses in providing and recording these essential care services, despite residents' dependence on staff and facility policy requirements.
A licensed pharmacist did not complete the required monthly drug regimen review, including the medical chart, and the facility failed to follow its own policies for reporting irregularities found during the review.
A resident with moderate cognitive impairment and multiple diagnoses expressed a desire to transfer to another facility, but staff did not document her request or any follow-up discussions. The facility failed to honor and facilitate the resident's right to self-determination, as required by policy.
The facility failed to maintain a proper grievance process for three residents, with issues including missing documentation, unresolved grievances, and lack of follow-up. A resident's missing clothing was not properly documented, another resident's missing money was not deposited into their trust account, and a third resident's complaint about cold meals was not resolved. The Social Service Director admitted to not addressing grievances comprehensively in QAPI meetings.
A resident's personal funds were not returned within 30 days of discharge. The facility failed to document and resolve a grievance regarding missing money. The Business Office Manager confirmed that $11 remained in the safe, and $4 was given to the resident without proper documentation.
Failure to Obtain HCS Consent Prior to Psychotropic Medication Changes
Penalty
Summary
The deficiency involves the facility’s failure to inform and obtain consent from a resident’s Health Care Surrogate (HCS) prior to initiating and changing psychotropic medications. The resident, who had diagnoses including other specified mood disorders, unspecified dementia with behavioral disturbance, major depressive disorder, and anxiety disorders, was admitted in 2025 and had severe cognitive impairment as evidenced by a BIMS score of 3 on a later MDS. The HCS reported that the facility did not communicate medication changes before they were implemented, specifically noting the initiation of Haldol and Depakote after the resident exhibited behavioral issues. The HCS expressed being upset that these changes were not communicated in advance. Interviews with staff confirmed that facility practice and expectation were that the HCS should be notified and consent obtained before starting psychotropic medications. Staff A, an LPN, stated that the unit manager was supposed to notify the family before starting psych medications and that there was no reason not to notify the HCS prior to initiating such medications; Staff A also stated the HCS had refused psychotropic medication for the resident. Staff B, an LPN and Unit Manager, described the process for obtaining psychotropic consent, including calling the HCS, explaining risks, documenting verbal consent on a psychotropic medication form, and uploading the form and a progress note to the medical record. However, Staff B acknowledged that Haldol was ordered on 04/11/2025 and administered on 04/26/2025, and that Depakote had been administered and later dose-adjusted in April 2025, without a psychotropic consent form signed prior to those administrations. Record review corroborated that the resident received multiple psychotropic medications before documented consent was obtained. The MAR showed administration of divalproex sodium 125 mg from 04/01/2025 through 04/13/2025, Depakote ER 250 mg from mid- to late April 2025, Depakote ER 500 mg starting 04/28/2025, and a Haldol injection on 04/26/2025. A psychotropic medication administration disclosure/consent form was dated 04/28/2025, and Staff B stated this was the first psychotropic consent form seen for Depakote, acknowledging it should have been signed before the resident received Depakote and Haldol. Progress notes documented behavioral issues and the use of Haldol for severe agitation, as well as a late entry note on 04/28/2025 indicating that a behavioral health provider assessed the resident and that a family member gave consent for medication at that time. The DON confirmed that consent should have been obtained for Haldol and Depakote prior to administration, that families were typically contacted before psychotropic medications were given, and that there was no documentation in the record confirming that the provider had notified the family before the medications were started.
Failure to Timely Assess and Respond to Change in Condition
Penalty
Summary
The facility failed to identify and assess a change in condition in a timely manner for a resident with multiple complex diagnoses, including multiple sclerosis, adult failure to thrive, a history of urinary tract infections, cystic liver disease, dysphagia, and abnormal weight loss. The resident was noted by a CNA to have decreased appetite and changes in behavior over several days, including being less responsive and not exhibiting her usual complaints during care. Despite these observations, the CNA's concerns were not promptly acted upon by nursing staff, and no documented assessments or vital signs were recorded during the period when the resident's condition was changing. On the day of the incident, both the CNA and the LPN observed that the resident was more tired than usual and not at her baseline. The LPN attributed the resident's fatigue to possible poor sleep and did not perform an assessment or obtain vital signs. The unit manager and the DON were also made aware of the resident's change in condition, but again, no assessment or vital signs were documented. The family was notified and requested a urinalysis, which was ordered, but staff were unable to obtain a sample. Later in the day, the resident was found to be unresponsive and hot to the touch, at which point she was sent to the hospital and subsequently admitted for sepsis and dehydration. The facility's documentation revealed a lack of timely and thorough assessment following reports of a change in condition, as well as gaps in monitoring and documentation of the resident's nutritional status and weight trends. The care plan for the resident included interventions for monitoring for signs of malnutrition, dehydration, and infection, but these were not effectively implemented. Facility policies and job descriptions require prompt assessment and documentation of changes in condition, but these were not followed in this case, resulting in a failure to provide necessary care and monitoring.
Failure to Honor Dietary Allergies, Intolerances, and Preferences
Penalty
Summary
The facility failed to ensure that food allergies, intolerances, and dietary preferences were honored for four out of five residents reviewed for nutritional services. One resident, who was a vegetarian with a moderate cognitive impairment, repeatedly received meals containing meat despite clear documentation of her dietary restrictions and multiple grievances filed on her behalf. The resident and her family communicated these concerns to staff, and the care plan specifically noted her vegetarian status and food preferences. Despite these measures, the resident continued to receive incorrect meals, leading to emotional distress and ultimately her discharge against medical advice. The facility was unable to provide a vegetarian menu to surveyors upon request, and meal tickets did not consistently reflect the resident's preferences or the interventions taken by dietary staff. Another resident with a documented shellfish allergy was served shrimp, contrary to the dietary order and meal ticket instructions. Staff interviews revealed that the process for assembling meal trays involved multiple checks, but the system failed, resulting in the resident being exposed to an allergen. The resident had a history of moderate allergic reactions to shellfish, and the care plan included clear instructions to avoid exposure. Staff confirmed that the resident had previously experienced a reaction to shrimp, and the allergy was documented in the medical record. Despite this, the resident was served shrimp, and the incident was only discovered after the meal was delivered. Additional deficiencies included a resident who was supposed to receive large portions but consistently received standard portions, and another resident with lactose intolerance and diabetes who was repeatedly served dairy products and sweets. In both cases, the residents' dietary needs were clearly documented in their records and on meal tickets, but the kitchen staff failed to provide the correct meals. These failures were confirmed through direct observation, interviews with residents and staff, and review of dietary documentation.
Failure to Complete Accurate PASARR Screenings for Residents with Mental Illness or Intellectual Disability
Penalty
Summary
The facility failed to ensure that Level I and Level II Preadmission Screening and Resident Review (PASARR) screenings were accurate and complete for 12 out of 14 sampled residents. Multiple residents were admitted with diagnoses such as bipolar disorder, schizoaffective disorder, major depressive disorder, generalized anxiety disorder, and other serious mental illnesses, yet their PASARR Level I screens either did not reflect these diagnoses or failed to indicate the need for a Level II evaluation. In several cases, the PASARR forms were incomplete, blank, or missing critical information, and no Level II PASARR was conducted despite qualifying diagnoses and evidence of functional impairment due to mental illness. Interviews with the Director of Nursing (DON) revealed that the facility's process for handling PASARR screenings was inconsistent and lacked oversight. The DON confirmed that PASARRs were not always available upon admission and that the responsibility for completing and updating PASARRs was assigned to social services staff, who were not consistently present or available. The DON also acknowledged that she did not verify the accuracy or completion of PASARRs and that there was no current access to the PASARR system by facility staff, resulting in delays or omissions in required screenings and referrals for Level II evaluations. The medical records reviewed showed that residents with significant psychiatric and behavioral diagnoses were not properly identified in the PASARR process, and in some cases, residents were receiving psychotropic medications and behavioral interventions without the required PASARR documentation. Facility policy required prompt referral for Level II PASARR when a serious mental disorder or intellectual disability was identified, but this was not consistently followed. The lack of accurate and timely PASARR screenings led to residents with serious mental illness or intellectual disability not being properly evaluated as required by federal regulations.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Follow Infection Control and Hand Hygiene Practices During Meal and Medication Service
Penalty
Summary
Multiple observations and interviews revealed that staff did not consistently follow infection prevention and control practices during meal service and medication administration. Staff members, including CNAs, the Activities Director, and dietary staff, were observed failing to perform hand hygiene between tasks such as passing meal trays, assisting residents, handling garbage, and touching their faces. In several instances, staff did not offer or assist residents with hand hygiene prior to meals, despite residents expressing a desire for such assistance. Additionally, hand sanitizer dispensers were found to be empty or inaccessible to residents who required help. Further deficiencies were noted in personal hygiene practices among staff. Several staff members, including CNAs and nurses, were observed with fingernails extending beyond the facility's policy limits and CDC recommendations, and with hair styles that could interfere with care. One CNA was seen repeatedly using a personal cloth to wipe perspiration from their face and then continuing to assist with meal service without performing hand hygiene. Staff interviews confirmed a lack of adherence to hand hygiene protocols, particularly after touching their faces or other potentially contaminated surfaces. The facility's own policies and CDC guidelines require hand hygiene before and after resident contact, after glove use, and after contact with potentially contaminated surfaces. However, staff interviews and direct observations indicated that these protocols were not consistently followed. Residents with moderate cognitive impairment were not offered hand hygiene before meals, and staff did not always perform hand hygiene as required by policy during medication administration and meal service. These lapses were confirmed by both staff and residents during interviews.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Address and Document Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were properly addressed and documented, as required by policy and regulation. Over a six-month period, concerns raised during resident council meetings, such as issues with cold food, call light response times, and dietary services, were not consistently logged as grievances, with only one grievance documented for the entire period. The Activities Director reported transcribing concerns from resident council meetings and submitting them as grievances to Social Services or the Nursing Home Administrator, but there was no evidence of follow-up or resolution communicated back to the resident council. Individual residents and their representatives also reported grievances that were not documented or resolved. One resident, who was cognitively intact and had hemiplegia, reported being treated rudely by a CNA and discussed the incident with an LPN and a Unit Manager. However, there was no record of a grievance being filed for this incident. Another resident's representative reported repeatedly raising concerns about call light response times to various staff members without receiving any resolution or follow-up. Similarly, a third resident's representative stated that concerns discussed with staff and the administrator were not addressed or followed up on, and no grievances were logged for these issues. Interviews with staff responsible for grievance management confirmed that grievances were not consistently logged or tracked for the concerns raised by residents and their representatives. The Social Services staff member acknowledged that grievances should have been written for the incidents described but were not. The facility's grievance policy outlines a process for logging, investigating, and resolving grievances, including prompt follow-up and written decisions, but this process was not followed in the cases reviewed. As a result, the facility did not ensure that residents' rights to voice grievances without discrimination or reprisal were honored, nor did it make prompt efforts to resolve grievances as required.
Failure to Provide Required Transfer/Discharge Documentation and Notification
Penalty
Summary
The facility failed to properly document and notify residents and their representatives regarding transfers or discharges, as required. For one resident with severe cognitive impairment and multiple mental health diagnoses, there was no documentation in the medical record of notifications to the resident or their representative when the resident was transferred to the hospital. The required Nursing Home Transfer and Discharge Notice (AHCA Form 3120-0002) was not found in the resident's records, nor was there evidence that the notice was given or mailed to the resident or their representative. Interviews with facility staff confirmed that the notice was not provided to residents or their representatives, but only faxed to the Ombudsman monthly. Another resident, with a history of cardiac and vascular conditions, was discharged home, but the discharge summary and instructions were incomplete and unsigned. The discharge documentation lacked essential information such as the primary physician, contact information for home health and medical equipment providers, and details on appointments, medication reconciliation, and disease management. There was also no evidence that the required transfer and discharge notice was present in the resident's records or that any information was provided to the resident upon discharge, as confirmed by the DON after reviewing the records.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
The facility failed to maintain a safe environment for residents by not securing accident hazards and not providing adequate supervision. Surveyors observed an unsecured and hot steam table in the North Wing Dining Room, with both entry doors open and unlocked, allowing residents unrestricted access to the steam table during meal service. Staff interviews confirmed that the steam table remained on and hot throughout breakfast and lunch, and the door meant to separate residents from the steam table was not consistently closed or locked. Additionally, two restrooms in the main hallway were found to lack emergency call cords near the toilets, despite being accessible to residents. Further deficiencies were identified regarding the storage of hazardous chemicals. On the Happy Trails unit, an unlocked cabinet in the dining/activity room contained a spray bottle of odor eliminator, and in the North Wing dining room, another unlocked cabinet contained a bottle of ant, roach, and fly spray. Both cabinets were accessible to residents at the time of observation. The DON acknowledged that these cabinets should have been locked to prevent resident access to hazardous substances. The facility also failed to provide required one-to-one supervision for a resident with a history of behavioral disturbances, including aggression and exit-seeking behaviors. Staff assigned to supervise the resident left the resident unattended in their room, contrary to physician orders and the resident's care plan, which called for continuous one-to-one supervision. The DON confirmed that staff should have remained within sight and close enough to intervene as needed. The resident's record indicated a history of agitation, aggression, and a prior incident of resident-to-resident abuse.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors among residents. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Medication Storage and Security Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of medications throughout the facility. Observations revealed that medication carts contained expired, undated, and loose medications, including vials of Albuterol/Ipratropium nebulizer medication not stored in their original packaging, an unlabeled vial without a resident name, and open bottles of Latanoprost ophthalmic drops and liquid protein that were not dated. Additional findings included loose pills and expired medications in medication carts, as well as expired Bisacodyl suppositories and vancomycin IV bags in the medication storage room. Staff interviews confirmed that nurses are responsible for cleaning their own carts, but expired and loose medications were still present. Controlled substances were not properly secured, as locked narcotic boxes in medication refrigerators were attached to removable shelves, making them unremovable as required. An emergency drug kit containing Lorazepam, a controlled substance, was also not securely attached in the refrigerator. CPR carts on two halls were found unlocked and contained glucose gel, and staff confirmed that all nurses have keys to these carts. Additionally, medications were observed left unsecured on top of medication carts and in resident rooms, including antacid tablets and an antibiotic vial at bedside, despite no residents being approved for self-administration of medications. Facility policy requires all drugs and biologicals to be stored in locked compartments and under proper conditions, with controlled substances in separately locked, permanently affixed compartments. The policy also mandates that medications must be under direct observation or locked during medication passes, and that expired or unused medications are to be routinely removed. Despite these policies, surveyors found multiple instances where medications were not properly labeled, stored, or secured, and staff interviews confirmed lapses in adherence to these protocols.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to maintain resident dignity during meal service on the East Wing, as evidenced by multiple observations and staff interviews. Residents seated together at dining tables did not receive their meal trays at the same time, resulting in some residents watching others eat or waiting extended periods for their own meals. In one instance, a resident who was asleep at the table awoke and consumed another resident's drink and ice cream while no staff were present in the dining room. Another resident was observed sitting with a half-eaten lunch and a blanket over his head, still at the table more than an hour after the meal had ended. Additionally, a resident was seen waiting outside her room for her meal tray while her roommate had already received hers, and other residents at a table received their trays several minutes apart. Staff interviews revealed a lack of training and awareness regarding the importance of serving meals simultaneously to residents seated together. CNAs and nursing staff indicated that meal trays are delivered based on room order and not coordinated for those dining together, and the kitchen staff were not informed about which residents eat in the dining room. The DON acknowledged that staff should be aware of the need to serve meals together and agreed that the observed practices were dignity concerns. Furthermore, a nurse was observed administering eye drops to a resident at the dining table, which was confirmed by the DON as inappropriate. The facility's policy on promoting and maintaining resident dignity was not followed, as staff actions did not ensure respect and dignity during meal times.
Failure to Ensure Safe and Individualized Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed, resulting in a deficiency related to resident care planning and transition.
Failure to Provide Adequate ADL Assistance for Grooming and Hygiene
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were completed for three residents, specifically in the areas of grooming, nail care, haircuts, and showers. One resident was observed with unkempt and matted hair, overgrown yellow fingernails with black debris, and expressed a desire for assistance with hair brushing and nail trimming. This resident was assessed as cognitively intact and dependent on staff for bathing and personal hygiene, with a care plan indicating the need for staff assistance in these areas. Despite these needs, the resident's grooming and hygiene were not adequately maintained. Another resident reported dissatisfaction with the length of their hair and the lack of available haircuts, noting that a beautician had not been present for several weeks. Staff interviews confirmed that the facility previously had a beautician who provided regular haircuts, but due to the beautician's absence, hair care services had lapsed. The process for residents to request haircuts was described, but it was also acknowledged that no beautician was currently available, and efforts to secure a replacement were ongoing. A third resident was observed with significant facial hair and stated a preference for being shaved, which was not consistently provided. Documentation and interviews revealed inconsistencies in the provision and recording of shaving assistance, with some shower logs lacking information on whether shaving was completed or if refusals occurred. The resident's care plan and progress notes did not address shaving needs or refusals, despite the resident's moderate cognitive impairment and dependence on staff for personal hygiene. The facility's ADL policy requires that residents unable to perform ADLs receive necessary services to maintain grooming and hygiene, but these requirements were not met for the residents reviewed.
Failure to Ensure Monthly Pharmacist Drug Regimen Review and Irregularity Reporting
Penalty
Summary
A licensed pharmacist did not perform a monthly drug regimen review, including a review of the medical chart, as required. The facility also failed to follow its developed policies and procedures for reporting irregularities identified during the drug regimen review process. This deficiency was identified during the survey based on the facility's lack of compliance with established guidelines for pharmacist review and reporting.
Failure to Support Resident's Choice to Transfer
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's right to self-determination by not supporting her expressed choice to transfer to another facility. The resident, who had a history of protein-calorie malnutrition, bipolar disorder, mood disorder, opioid dependence, and generalized anxiety disorder, communicated her desire to move to another facility but reported that her requests were ignored and not acted upon. The resident had a moderate cognitive impairment, as indicated by a BIMS score of 10 out of 15. There was no documentation in her progress notes or the facility's grievance log regarding her request or any follow-up actions taken by staff. Interviews with the Social Services Assistant revealed that although she was aware of the resident's wish to transfer and had discussed it with her, she did not document the conversation or any change in the resident's wishes. The facility's policy requires informing residents of their rights and documenting relevant information, but there was no evidence that the resident's request or subsequent discussions were recorded. This lack of documentation and follow-up resulted in the facility failing to promote and facilitate the resident's right to make choices about her care and living arrangements.
Deficient Grievance Process in LTC Facility
Penalty
Summary
The facility failed to ensure a functioning grievance process for three residents, as evidenced by the lack of proper documentation and follow-up on grievances. For Resident #1, the facility's grievance log showed two grievances regarding hydration preference and room cleanliness, both marked as resolved. However, a concern about missing clothing items was not properly documented or resolved. The Social Service Director (SSD) had only a post note with no specific details, and the missing items list was incomplete. The SSD offered $100 to the family verbally, but there was no documentation of this offer being made or accepted. Resident #2's grievance involved missing money and clothing items. The grievance log had incomplete documentation, lacking details about the person making the complaint and whether the grievance was resolved. The SSD confirmed that the money was replaced, but the Business Office Manager (BOM) revealed that the money was never deposited into the resident's trust account and remained in the safe. The BOM also noted discrepancies in the documentation of the money returned to the resident. For Resident #9, the grievance log showed two grievances: one about cold meals and another about broken call lights. The resolution for the cold meal grievance was not documented, and the resident confirmed that the issue persisted. The call light grievance lacked documentation of who investigated it, and while some corrective actions were noted, the resident reported no follow-up on the cold meal issue. The SSD admitted to not discussing grievances comprehensively in Quality Assurance and Performance Improvement (QAPI) meetings, indicating a systemic issue in handling grievances effectively.
Failure to Return Resident's Personal Funds Post-Discharge
Penalty
Summary
The facility failed to convey personal funds deposited with the facility within 30 days of discharge for a resident. The resident was admitted to the facility and subsequently discharged on a specified date. However, a balance of $11.00 in the resident's personal trust account was not returned. A grievance was filed regarding the missing money, but the grievance form lacked documentation of the person making the complaint, their relationship to the resident, and whether the grievance had been resolved. The Social Services Director (SSD) acknowledged the grievance but did not have documentation of the amount of money involved. The Business Office Manager (BOM) presented a receipt for $15.00 intended for the resident's trust account, which was never deposited. Instead, the money remained in the safe, and $4 was given to the resident without proper documentation or signatures. The BOM confirmed the remaining $11 was still in the safe, and the discrepancy was not resolved. The Nursing Home Administrator (NHA) indicated plans to initiate training on handling missing items and grievances, but this was not part of the deficiency itself.
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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