Lake Wales Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Wales, Florida.
- Location
- 730 N Scenic Hwy, Lake Wales, Florida 33853
- CMS Provider Number
- 106069
- Inspections on file
- 21
- Latest survey
- June 24, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Lake Wales Health And Rehabilitation Center during CMS and state inspections, most recent first.
A deficiency occurred when a resident's room remained excessively hot, with temperatures near 90°F, due to an unrepaired rooftop A/C unit. The resident, who was nonverbal and medically complex, experienced physical discomfort for about a month while staff and maintenance were aware of the issue but did not routinely monitor or document room temperatures. Leadership lacked a formal process for temperature checks or maintenance reporting, and no policies were provided to ensure compliance.
A resident with severe disabilities was exposed to excessively high room temperatures due to a malfunctioning A/C unit, with temperatures reaching nearly 90°F. Multiple staff, including LPNs and CNAs, were aware of the issue for weeks, but no maintenance requests were documented and routine temperature monitoring was not performed. Facility leadership and maintenance staff were unaware of the ongoing problem, and the resident, who was unable to communicate discomfort, remained in the overheated room until the issue was discovered during a survey.
The facility failed to prevent neglect and medication errors, including not providing physician-ordered tube feeding and mobility assistance for a resident, leading to functional decline, and failing to administer medications as ordered for two residents. One resident missed multiple doses of IV antibiotics due to pharmacy and documentation issues, and another received the wrong IV medication due to staff error and lack of proper certification. Required assessments and investigations were not completed according to policy.
The facility did not keep nurse staffing postings current, as the displayed information was outdated for an extended period. The Staffing Coordinator, responsible for updating the postings, did not ensure they were updated, and the Nursing Home Administrator did not verify the postings as usual. There was no policy in place for posting nurse staffing data.
A resident with multiple complex medical conditions was given the wrong IV medication due to a medication error. Although the error was identified and reported, the facility did not conduct a thorough investigation or provide timely education to the involved LPNs on medication administration rights. The facility's documentation and staff interviews confirmed that required follow-up actions and staff training were not completed as per policy.
A resident with COPD and a physician's order for continuous oxygen was observed multiple times with an empty portable oxygen tank, resulting in a lack of oxygen delivery despite the nasal cannula being in place. Staff interviews revealed confusion over responsibilities for changing and initiating oxygen tanks, and the facility's policy limited initiation of oxygen therapy to licensed personnel. Full oxygen tanks were available in storage, but the resident did not receive the ordered therapy for an extended period.
Nurses and nurse aides failed to demonstrate appropriate competencies in medication administration, resulting in three residents not receiving medications as ordered. Errors included administering the wrong IV medication, missing multiple doses of an IV antibiotic due to supply and communication issues, and improper administration of eye drops and probiotics. Staff interviews revealed gaps in training, lack of policy adherence, and incomplete documentation.
Two residents did not receive their routine, physician-ordered medications upon admission due to the facility's failure to acquire and administer the medications in a timely manner. Despite the availability of some medications in the emergency drug kit, staff did not document attempts to access or administer them, and there was no clear communication with physicians regarding alternatives. Leadership confirmed the absence of policies guiding medication acquisition and use of the EDK, resulting in missed doses for newly admitted residents.
A medication pass observation revealed a 25% error rate when an LPN administered the wrong probiotic, failed to wait the recommended interval between two different eye drops, and gave both drops consecutively to a resident with diabetes and recent eye surgery. The MAR indicated the ordered probiotic was not given, and there was no facility policy for eye drop administration.
The facility's kitchen cooler was found in unsanitary condition, with peeling racks exposing rust and brownish-yellow stains. Various food items were stored improperly. The Dietary Director was aware of the issue but had not submitted a work order, and the Maintenance Director confirmed no work orders were received.
The facility did not have a qualified Infection Control Preventionist (ICP) with specialized training. The DON and an LPN were in training to become ICPs, but neither had completed the required training. Their training was assisted by a Regional Nurse Consultant who visits monthly. The previous ICP left in May, and the facility's policy mandates specialized training for the ICP role, which was not fulfilled.
The facility failed to maintain essential kitchen equipment safely, with a leaking reach-in cooler and steam table observed during a survey. Staff confirmed the issues and mentioned maintenance requests, but the Maintenance Director had not received any work orders. A review of work orders for May and June 2024 showed no records for the equipment, indicating a communication breakdown.
The facility failed to maintain accurate PASRR documentation for several residents, as their forms did not reflect current mental health diagnoses. This was confirmed through interviews and record reviews, revealing discrepancies between the PASRR forms and the residents' medical records and MDS assessments. The DON and SSD acknowledged their responsibility to ensure PASRR accuracy, but the process was not consistently followed.
The facility failed to complete MDS assessments on time for four residents, with delays attributed to other departments not completing their sections promptly. Two residents had their admission MDS assessments completed late, while two others had their Medicare 5-day MDS assessments delayed beyond the required timeframe.
A resident with unspecified hearing loss was inaccurately assessed in their MDS as having adequate hearing, despite requiring a dry erase board for communication. Facility staff, including the MDS Coordinator and DON, confirmed the error, acknowledging the resident's care plan for hearing difficulties. The facility's policy requires accurate assessments to meet residents' needs, which was not followed in this instance.
A resident's baseline care plan was not completed within the required timeframe after admission. Interviews with an LPN and the DON revealed confusion about the timeline for completing these plans, and the facility lacked a formal policy for baseline care plans.
The facility failed to update care plans for four residents, leading to deficiencies in care. One resident's care plan was not revised after transmission-based precautions were lifted. Another resident's laughing outbursts were not addressed in the care plan, despite a diagnosis of pseudobulbar affect. A third resident's care plan lacked interventions for skin-picking and wound care. Additionally, a resident receiving oxygen therapy had a care plan that did not include their oxygen, diabetes, or dysphagia needs.
The facility failed to provide proper oxygen therapy for four residents, with issues including lack of physician orders, improper documentation, and absence of signage indicating oxygen use. Residents were observed using oxygen at incorrect levels, and staff interviews revealed inconsistencies in monitoring and adjusting oxygen therapy according to physician orders.
A facility failed to limit PRN psychotropic medications to 14 days for a resident with mood disorder and dementia, and did not complete behavior and side effect monitoring for four residents as per physician orders. The MAR showed check marks instead of required documentation, indicating a lack of proper monitoring and documentation.
Failure to Maintain Safe Room Temperatures Due to Unrepaired A/C Unit
Penalty
Summary
A deficiency was identified when the facility failed to maintain safe and comfortable temperatures in a resident's bedroom due to an unrepaired rooftop air-conditioning (A/C) unit. Observations revealed that the resident's room had temperatures between 89.8 and 90.0 degrees Fahrenheit, with noticeable humidity and lack of cool airflow. The resident, who was nonverbal and dependent on staff for care, was found in a visibly uncomfortable state, with staff noting the room had been warm for about a month. Multiple staff members, including CNAs and LPNs, confirmed awareness of the persistent high temperatures in the room, and it was noted that the issue had not been formally reported or addressed in the facility's electronic communication log. The resident involved had significant medical conditions, including severe intellectual disabilities, acute and chronic respiratory failure, contractures, cognitive communication deficits, and generalized muscle weakness, necessitating assistance with personal care. The resident was unable to communicate preferences or discomfort regarding room temperature. Despite the resident's vulnerability, the maintenance staff had not routinely checked or documented room temperatures, and the Maintenance Director only measured the temperature after being prompted during the survey. The Maintenance Assistant and Director both expressed expectations for room temperatures to be significantly lower than what was observed, and acknowledged that the conditions were unsuitable for a resident. Interviews with facility leadership, including the DON and NHA, revealed a lack of awareness and formal process for monitoring and documenting room temperatures. The NHA stated that temperature checks were only performed in response to A/C outages and that staff were expected to report issues through an electronic system, though no such reports were found. The facility did not provide policies or procedures for temperature monitoring or staff communication regarding maintenance concerns. The deficiency was cited due to the failure to ensure the physical environment was maintained in a manner that assured resident safety and well-being, as required by regulation.
Plan Of Correction
Resident #5 was immediately moved to another room on 06/23/2025 with no adverse effects noted. Room #202 was closed on 06/23/2025. On 06/23/2025, a portable air conditioner was placed in room 202. An outside HVAC contractor detected a refrigerant leak on 06/26/2025; a recommendation for roof top unit (RTU) #3 replacement was received. A replacement unit was ordered on 06/26/2025. On 08/30/2025, an outside HVAC contractor added refrigerant to RTU #3. The new unit was installed on 07/11/2025 by an outside HVAC contractor. On 06/25/2025, the Maintenance Director tested room and hallway temperatures with no concerns identified. On 06/26/2025, an outside HVAC contractor completed a system check for the remaining RTUs to determine functionality. The recommendation was for the replacement of RTU #5, which was received. The replacement unit was ordered on 06/26/2025. No other recommendations were received for the remaining units. The NHA re-educated the Maintenance Director on 06/25/2025 on comfortable and safe temperature levels. Facility staff were re-educated on comfortable and safe temperature levels and submitting electronic work orders by 07/14/2025. Any staff not receiving education by 07/14/2025 will receive education prior to their next scheduled shift. The Maintenance Director/designee will complete random audits of temperatures in hallways and resident rooms 5 times a week for 4 weeks, 3 times a week for 4 weeks, and 1 time a week for one month. Any concerns will be addressed at the time of audit. Audit results, along with any concerns related to compliance, will be presented to the QA Committee (Administrator, Director of Nursing, Medical Director, MDS Coordinator, Social Services Director, Admissions Director, Maintenance Supervisor, Dietary Director) monthly at the Quality Assurance Performance Improvement meeting for review and any needed recommendations for 3 months. If non-compliance is identified, audits will start back at the beginning of the cycle occurring 4 weeks, 3 times a week for 4 weeks, and 1 time a week for one month.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
A deficiency occurred when the facility failed to maintain safe and comfortable temperatures in a resident's bedroom, as required by federal regulations. The air conditioning (A/C) system serving the resident's room was not functioning properly, resulting in room temperatures measured between 89.8 and 90.0 degrees Fahrenheit. Observations confirmed excessive warmth and palpable humidity in the room, with no noticeable cool air flow from the ceiling vent. The resident, who was nonverbal and dependent on staff for care, was found in a visibly uncomfortable state, with staff noting that the room had been warm for about a month. Multiple staff members, including LPNs, CNAs, and housekeeping, were aware of the elevated temperatures in the room and reported that the issue had persisted for several weeks. Despite this, there was no evidence that maintenance staff or facility leadership had taken timely action to monitor or address the temperature problem. The maintenance director and assistant were unaware of any recent complaints or issues with the A/C unit, and temperature checks in resident rooms were not routinely performed unless the A/C system was known to be out of order. Staff reported that maintenance requests were to be submitted electronically, but no such requests regarding the temperature issue were found in the facility's communication log. The resident affected by the deficiency had significant medical needs, including severe intellectual disabilities, respiratory failure, contractures, and muscle weakness, and was unable to communicate preferences or discomfort. The facility did not have a documented policy or procedure for routine temperature monitoring or for staff to communicate environmental concerns to maintenance. Facility leadership, including the DON and NHA, were not aware of the temperature issue in the resident's room and had not noticed elevated temperatures in the affected area. The lack of routine monitoring and communication resulted in the resident being exposed to unsafe and uncomfortable temperatures for an extended period.
Plan Of Correction
Resident #5 was immediately moved to another room on 06/23/2025 with no adverse effects noted. Room #202 was closed on 06/23/2025. On 06/23/2025, a portable air conditioner was placed in room 202. An outside HVAC contractor detected a refrigerant leak on 06/26/2025; a recommendation for roof top unit (RTU) #3 replacement was received. A replacement unit was ordered on 06/26/2025. On 06/30/2025, the outside HVAC contractor added refrigerant to RTU #3. The new unit was installed on 07/11/2025 by an outside HVAC contractor. On 06/25/2025, the Maintenance Director tested room and hallway temperatures with no concerns identified. On 06/26/2025, an outside HVAC contractor completed a system check for the remaining RTUs to determine functionality. The recommendation was for the replacement of RTU #5, which was received. The replacement unit was ordered on 06/26/2025. No other recommendations were received for the remaining units. The NHA re-educated the Maintenance Director on 06/25/2025 on comfortable and safe temperature levels. Facility staff were re-educated on comfortable and safe temperature levels and submitting electronic work orders by 07/14/2025. Any staff not receiving education by 07/14/2025 will receive education prior to their next scheduled shift. The Maintenance Director/designee will complete random audits of temperatures in hallways and resident rooms 5 times a week for 4 weeks, 3 times a week for 4 weeks, and 1 time a week for one month. Any concerns will be addressed at the time of audit. Audit results along with any concerns related to compliance will be presented to the QA Committee (Administrator, Director of Nursing, Medical Director, MDS Coordinator, Social Services Director, Admissions Director, Maintenance Supervisor, Dietary Director) monthly at the Quality Assurance Performance Improvement meeting for review and any needed recommendations for 3 months. If non-compliance is identified, audits will start back at the beginning of the cycle occurring 4 weeks, 3 times a week for 4 weeks, and 1 time a week for one month.
Failure to Prevent Neglect and Medication Errors
Penalty
Summary
The facility failed to protect residents from neglect by not providing physician-ordered tube feeding and failing to assist a resident in getting out of bed for 13 days, resulting in a decline in the resident's functionality. The resident, who was admitted with multiple serious diagnoses including sepsis, acute respiratory failure, and protein-calorie malnutrition, was supposed to receive enteral nutrition via a tube feed and assistance with mobility. Observations and interviews revealed that the tube feeding was inconsistently administered due to issues with the pump and lack of staff knowledge, and the resident was not assisted out of bed because staff were waiting on therapy and a wheelchair was missing. Documentation showed missed and undocumented feedings, and the resident experienced weight loss and a decline in physical function during this period. Additionally, the facility failed to administer medications in accordance with physician orders for two residents. One resident did not receive all prescribed doses of an IV antibiotic due to pharmacy supply issues and lack of proper tracking, resulting in missed doses and the premature removal of a PICC line before the antibiotic course was completed. Staff interviews confirmed confusion and lack of communication regarding the medication schedule, and documentation did not support that the full course was administered as ordered. Another resident received the wrong IV medication due to a medication administration error involving two LPNs, one of whom was not IV certified. The error was not fully investigated, and required neurological assessments were not completed as ordered. Facility policies on medication administration and abuse prevention were not followed, and staff involved did not receive appropriate education or oversight regarding medication rights and administration procedures.
Failure to Maintain Up-to-Date Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that the posted nurse staffing data was up-to-date and current for the period from 4/18/25 to 4/30/25. Observations on 4/29/25 revealed that the Daily Nurse Staffing sheet displayed in the front lobby was dated 4/17/25 and had not been updated through at least 4/29/25. Interviews with the Staffing Coordinator confirmed she was responsible for posting the data but had not ensured it was done, citing changes in her work schedule and not realizing the postings were outdated. The Nursing Home Administrator also acknowledged that she typically checked the postings but had not done so during this period. It was further confirmed that the facility did not have a policy regarding the posting of Daily Nurse Staffing data. Photographic evidence was obtained to support these findings.
Failure to Investigate and Educate Staff After Medication Error
Penalty
Summary
The facility failed to thoroughly investigate and provide staff education following a medication error involving a resident who was admitted with multiple complex diagnoses, including intraspinal abscess, sepsis, and chronic myeloproliferative disease. The resident was inadvertently administered the wrong intravenous medication, Cefepime HCl, instead of the ordered Daptomycin. Documentation shows that the error was identified, the physician and family were notified, and neuro checks were initiated, but there was no evidence of adverse reactions at the time. However, the facility's progress notes lacked a follow-up entry for the day after the incident. Interviews revealed that the investigation into the medication error was incomplete. The DON, who was new to the position, provided only one investigation statement from the LPN involved and acknowledged that the form was not filled out correctly. The DON also stated that there was no proof that staff education on the seven rights of medication administration had been provided at the time of the incident. Other staff members confirmed that they had not received formal education related to medication rights or incident response until much later. The facility's policy requires immediate and thorough investigation of alleged neglect, including obtaining statements from all involved staff and providing education to prevent recurrence. In this case, the investigation did not include statements from all relevant staff, and there was no documentation of timely staff education. The lack of a comprehensive investigation and staff training following the medication error constituted a failure to respond appropriately to an alleged violation, as required by facility policy.
Failure to Provide Continuous Oxygen Therapy as Ordered
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD) and a physician's order for continuous oxygen at 2 liters via nasal cannula was observed multiple times throughout the day with an empty portable oxygen tank. The resident, who required oxygen due to asthma and reported episodes of wheezing, was seen in her wheelchair both in her room and on the patio with the nasal cannula in place but no oxygen being delivered, as the tank was empty. This was confirmed by several staff members, including CNAs and a registered nurse, who acknowledged that the oxygen tank had been empty since the morning and had not been replaced as required by the resident's care plan and physician's orders. Interviews with staff revealed confusion regarding responsibilities for changing and initiating portable oxygen tanks, with CNAs stating they typically changed the tanks and nurses indicating that only licensed staff should initiate oxygen therapy. The facility's policy specified that only physicians, RNs, LPNs, and respiratory therapists are authorized to initiate oxygen therapy. Despite the availability of full oxygen tanks in storage, the resident did not receive the ordered continuous oxygen therapy for an extended period, as evidenced by direct observation and staff interviews.
Medication Administration Competency Deficiencies
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the appropriate competencies and skills to administer medications as ordered for three residents. In one case, a resident with complex medical conditions, including sepsis and osteomyelitis, was given the wrong intravenous medication due to a lack of verification and proper handoff between two LPNs, one of whom was not IV certified. The medication error was not fully investigated, and required neurological assessments were not completed according to protocol, with documentation ceasing before the required monitoring period ended. Staff interviews revealed gaps in education regarding medication rights and incident response procedures. Another resident, admitted with sepsis and other serious diagnoses, did not receive all prescribed doses of an IV antibiotic due to medication unavailability and communication lapses. The MAR and progress notes showed that eight doses were missed, and documentation was inconsistent regarding physician notification and medication holds. Staff interviews confirmed difficulties in obtaining the medication and confusion about whether the full course was completed. The resident's PICC line was discontinued before the antibiotic regimen was finished, necessitating reinsertion for completion of therapy. A third resident experienced multiple medication administration errors during observation. An LPN administered a probiotic that was not the same as the one ordered, and two different eye drops were given consecutively without the recommended interval between administrations. The facility lacked a policy for eye drop administration, and staff were unclear about the equivalency of probiotics. These incidents demonstrate failures in medication verification, adherence to administration protocols, and staff competency in medication management.
Failure to Provide Admission Medications Due to Gaps in Acquisition and Documentation
Penalty
Summary
The facility failed to ensure that routine, physician-ordered medications were acquired and provided upon admission for two residents. For one resident with multiple diagnoses including a right femur fracture, chronic pain, asthma, fibromyalgia, and migraines, there was no documentation of medication reconciliation or communication with the physician at admission. Progress notes indicated that several ordered medications, including Lyrica, Eletriptan, Venlafaxine, and Senokot S, were not available or administered for up to three days after admission. The medication administration record confirmed these medications were not given, and staff documented that medications were pending pharmacy delivery or not available, with some offers of alternative pain relief being refused by the resident. Another resident, admitted with diagnoses such as spondylosis, type 2 diabetes with nephropathy, muscle spasm, bacteremia, and repeated falls, also did not receive ordered medications upon admission. The resident reported not receiving any medications, including those for diabetes, during the first night, which was corroborated by the medication administration record and progress notes. The facility's emergency drug kit (EDK) contained metformin and other relevant medications, but there was no documentation that these were accessed or administered. Staff interviews revealed inconsistent processes for obtaining and administering medications from the EDK and pharmacy, with some staff indicating that medications could be delayed depending on delivery schedules and lack of clear documentation or communication with physicians regarding alternatives. Further interviews with facility leadership, including the DON and NHA, confirmed gaps in the medication acquisition process, lack of documentation regarding medication availability, and absence of policies related to obtaining medications from pharmacy services or the EDK. The DON acknowledged that medications such as metformin and rosuvastatin were available in the EDK but could not confirm why they were not administered. The NHA stated there were no policies guiding the acquisition of medications or use of the EDK, contributing to the failure to provide necessary medications to residents upon admission.
Medication Administration Error Rate Exceeds 5% Due to Multiple Errors
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, as required. During an observation of medication administration for one resident, a total of twelve medication opportunities were reviewed, and three errors were identified, resulting in a 25% error rate. The errors included the administration of saccharomyces boulardii instead of the ordered lactobacillus probiotic, failure to wait the recommended interval between administering two different types of eye drops (latanoprost and timolol) in the same eye, and the administration of both eye drops consecutively without the required waiting period. The staff member involved confirmed the administration of the incorrect probiotic and did not follow the recommended procedure for eye drop administration. The resident involved had a history of diabetes mellitus and recent eye surgery, with orders for multiple oral medications, eye drops for glaucoma, and insulin. The medication administration record showed that the resident was to receive lactobacillus, but this was substituted with saccharomyces without a corresponding order at the time of administration. Additionally, the facility did not have a policy or procedure in place for the administration of eye drops, and staff were not following best practices for timing between different ophthalmic medications. These actions and omissions led to the identified medication errors.
Sanitation Deficiency in Kitchen Cooler
Penalty
Summary
The facility failed to maintain the reach-in cooler in a sanitary condition within the kitchen. During an inspection, the cooler was found to contain various food items, including a container of prepared food, an open carton of eggs, a container of turkey, half a head of lettuce, a cucumber, a package of meat, and a silver pan of corn, all covered with plastic wrap. The cooler's racks were observed to have peeling white coating, exposing rusted bars, and were stained with a brownish-yellow residue. The Dietary Director acknowledged the need to replace the racks and expressed a desire to replace the entire cooler. However, she was unaware of when a work order was submitted, despite the facility using an online system for such requests. The Maintenance Director confirmed that no work orders for the cooler had been received. A review of the facility's work order report for May and June 2024 showed no entries for the reach-in cooler.
Lack of Qualified Infection Control Preventionist
Penalty
Summary
The facility failed to ensure the presence of a qualified Infection Control Preventionist (ICP) with specialized training in infection control and prevention. During an interview, the Director of Nursing (DON) stated that both she and a Licensed Practical Nurse (LPN), referred to as Staff C, were in training to become the facility's ICPs. However, neither had completed the necessary specialized training. The DON mentioned that their training was being assisted by a Regional Nurse Consultant (RNC) who visits the facility once a month. The Nursing Home Administrator confirmed that the previous ICP left in May 2024, and currently, the DON and Staff C are undergoing training. The facility's policy requires that the ICP must have specialized training beyond initial professional education before assuming the role, which neither the DON nor Staff C had completed at the time of the survey.
Failure to Maintain Essential Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in a safe operating condition, as observed during a survey. The reach-in cooler was found with a wet towel underneath and water pooling on the floor, indicating a leak. Additionally, the steam table was observed with wet towels and buckets on the lower shelf to catch water dripping from the upper shelf where food storage compartments were located. Staff E, a dietary staff member, confirmed the leaks and mentioned that a maintenance request had been submitted, although the drain was missing on the steam table, necessitating the use of buckets. The Dietary Director acknowledged that the reach-in cooler had been temporarily fixed by on-site maintenance and that the steam table did not leak consistently. However, the Maintenance Director stated that he had not received any work orders for either the reach-in cooler or the steam table. He only became aware of the issues when informed by the kitchen staff during the survey. A review of the facility's work order report for May and June 2024 showed no records of work orders for the problematic equipment, indicating a communication breakdown in the maintenance request process.
Inaccurate PASRR Documentation for Residents
Penalty
Summary
The facility failed to ensure the accuracy of admission diagnoses on the Level I Preadmission Screening and Resident Review (PASRR) forms and did not update these forms upon the addition of new diagnoses for thirteen residents. This deficiency was identified through interviews and record reviews, revealing that the PASRR forms for these residents were not accurately reflecting their current mental health diagnoses. For instance, Resident #43's PASRR form did not include updated diagnoses of vascular dementia and adjustment disorder with mixed anxiety and depressed mood, despite these being documented in the resident's medical records and medication administration records. Similarly, Resident #40's PASRR form was outdated and did not reflect the resident's current diagnoses of unspecified dementia and major depressive disorder. The review of the medication administration records and Minimum Data Set (MDS) assessments for several residents, including Residents #6, #59, and #37, showed discrepancies between the documented diagnoses and those listed on the PASRR forms. These inconsistencies indicate a failure to update the PASRR forms as required when new diagnoses were made or when residents were readmitted to the facility. Interviews with the Director of Nursing (DON) and the Social Services Director (SSD) confirmed that it was their responsibility to ensure the accuracy of the PASRR forms upon admission and to update them when new diagnoses were added. However, the review of the clinical records showed that this process was not consistently followed, leading to multiple residents having inaccurate PASRR forms. This oversight in maintaining accurate PASRR documentation could potentially impact the care and services provided to residents with mental disorders or intellectual disabilities.
Delayed Completion of MDS Assessments
Penalty
Summary
The facility failed to ensure the timely completion of the Minimum Data Set (MDS) assessments for four residents, which is a requirement for comprehensive resident assessment. Resident #47's admission MDS assessment was completed late, with an Assessment Reference Date (ARD) of 5/28/2024, but not completed until 6/5/2024. Similarly, Resident #273's admission MDS assessment was delayed, with an ARD of 6/12/2024, but not completed until 6/20/2024. These delays were acknowledged by Staff B, the Registered Nurse and MDS Coordinator, who attributed the lateness to other departments not completing their sections of the assessment on time. Additionally, the facility did not complete the Medicare 5-day MDS assessments for Resident #57 and Resident #17 within the required timeframe. Resident #57 was discharged on 2/3/2024, but the assessment was not completed until 3/20/2024. Similarly, Resident #17 was discharged on 1/4/2024, with the assessment also completed on 3/20/2024. Staff B was unable to provide reasons for these delays as she was not employed at the facility during that period. According to the Centers for Medicare & Medicaid Services guidelines, these assessments should have been completed within 14 days of the ARD.
Inaccurate MDS Assessment for Hearing Impaired Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident with a diagnosis of unspecified hearing loss. The resident was observed in a wheelchair watching television and communicated using a dry erase board, indicating a significant hearing impairment. Despite this, the resident's Quarterly MDS assessment inaccurately documented that the resident had adequate hearing with no difficulty in normal conversation, social interaction, or listening to TV. This discrepancy was identified during a review of the resident's care plan, which had interventions in place for hearing difficulties, such as using a dry erase board for communication. Interviews with the facility staff, including the MDS Coordinator and the Director of Nursing (DON), confirmed the inaccuracy in the MDS assessment. The MDS Coordinator acknowledged the error, noting that the resident was care planned for difficulty hearing, and the DON confirmed that the resident was unable to hear and required the use of a dry erase board for communication. The facility's policy on comprehensive care plans emphasizes the need for accurate assessments to meet residents' needs, which was not adhered to in this case.
Failure to Timely Complete Baseline Care Plan
Penalty
Summary
The facility failed to complete a baseline care plan in a timely manner for a resident, identified as #274, who was admitted on an unspecified date. The baseline care plan for this resident was not completed until 6/17/2024, which was beyond the expected timeframe. Interviews with staff revealed a lack of clarity regarding the timeline for completing baseline care plans. A Licensed Practical Nurse (LPN) indicated that unit managers typically initiate these plans, but could not specify when they should be completed. The Director of Nursing (DON) stated that baseline care plans should be completed by the admitting nurse within 48 hours of admission. However, the facility did not have a formal policy in place for baseline care plans, as confirmed by the DON.
Failure to Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to revise the comprehensive care plans for four residents, leading to deficiencies in their care. For one resident with a history of ESBL in urine, the care plan was not updated to reflect the discontinuation of transmission-based precautions, despite the precautions being lifted weeks prior. The oversight was confirmed by the RN/MDS Coordinator, who acknowledged the care plan should have been updated when the precautions were no longer necessary. Another resident, diagnosed with Alzheimer's disease and other mental health conditions, exhibited sporadic outbursts of laughter, which were not addressed in the care plan. Despite a diagnosis of pseudobulbar affect and a recommendation for Nuedexta, there were no orders for the medication, and the care plan lacked any focus, goal, or intervention related to the laughing outbursts. Staff interviews revealed a lack of communication regarding the new diagnosis and the absence of documentation in the care plan. A third resident with a history of skin-picking disorder and venous ulcers had a care plan that did not address the behavior of removing dressings from wounds. The resident's care plan was also missing goals and interventions for the venous ulcers and did not include care for a toe wound. Staff interviews indicated a lack of awareness and communication about the resident's behavior and wound care needs. Additionally, another resident receiving oxygen therapy and diagnosed with diabetes and dysphagia had a care plan that did not include these conditions, highlighting a failure to update the care plan to reflect the resident's current needs.
Oxygen Therapy Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide oxygen therapy in accordance with professional standards for four residents. Resident #47 was observed using oxygen without proper documentation in the medication administration record, and there was no signage indicating oxygen use outside the resident's room. Despite having a physician's order for PRN oxygen, the administration was not recorded, indicating a lack of adherence to the prescribed treatment plan. Resident #274, who has chronic obstructive pulmonary disease and is dependent on supplemental oxygen, was observed using oxygen without a physician's order in place. The staff, including an LPN and the Director of Nursing, confirmed the absence of an order and acknowledged the lack of signage indicating oxygen use. This oversight highlights a failure in ensuring that physician orders are documented and followed, as well as a lack of communication regarding oxygen therapy protocols. Resident #14 was receiving oxygen therapy at a higher rate than prescribed, with no documentation of the administration in the medication record and no signage indicating oxygen use. Similarly, Resident #29 was observed using oxygen at a lower rate than ordered, with the resident unaware of the prescribed oxygen level. Interviews with staff revealed inconsistencies in monitoring and adjusting oxygen levels according to physician orders, further demonstrating a systemic issue in managing oxygen therapy for residents.
Failure to Limit PRN Psychotropic Medications and Monitor Side Effects
Penalty
Summary
The facility failed to ensure that physician-ordered psychotropic medications used on an as-needed basis were limited to 14 days for one resident. This resident was admitted with diagnoses of mood disorder and dementia and had an order for Lorazepam without an end date. The Director of Nursing acknowledged that psychotropic medications should be limited to 14 days and reviewed by the physician if continued use is necessary. The facility's policy requires that PRN orders for psychotropic drugs be limited to 14 days unless the physician documents a rationale for extension. Additionally, the facility did not complete behavior and side effect monitoring of psychotropic medication use in accordance with physician orders for four residents. For one resident, the Medication Administration Record (MAR) showed check marks instead of the required 'Yes' or 'No' documentation for monitoring behaviors and side effects. This resident had a history of Alzheimer's disease, mood disorder, and other psychiatric conditions, and was observed having sporadic outbursts of laughter. Staff interviews revealed a lack of documentation and communication regarding the resident's behavior and medication administration. For another resident, the MAR also showed check marks instead of the required documentation for monitoring behaviors and side effects. This resident had a diagnosis of depression and was observed sleeping frequently. The care plan indicated a risk for adverse reactions to psychotropic medications, but the required monitoring was not documented. Similar issues were found with two other residents, where the MAR showed check marks instead of the required documentation, indicating a failure to monitor and document behaviors and side effects as per physician orders and facility policy.
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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