Legacy At Boca Raton Rehabilitation And Nursing Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Boca Raton, Florida.
- Location
- 6363 Verde Trail, Boca Raton, Florida 33433
- CMS Provider Number
- 105476
- Inspections on file
- 21
- Latest survey
- August 7, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Legacy At Boca Raton Rehabilitation And Nursing Ce during CMS and state inspections, most recent first.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet needs.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors during the review of care practices.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs. These deficiencies were observed during the survey and directly impacted residents requiring assistance with bowel and bladder management.
A resident did not receive safe and appropriate respiratory care when needed, as required by facility protocols.
Two residents experienced medication administration errors when LPNs failed to follow physician orders: one was not instructed to rinse her mouth after inhaled medication for COPD, and another received a medication mixed with less water than ordered due to lack of appropriate cup size. The errors were confirmed by the DON and staff, resulting in a medication error rate above the acceptable threshold.
Surveyors found that a resident did not receive appropriate care for bowel/bladder continence or incontinence, including inadequate catheter care and insufficient prevention of UTIs. These failures resulted in a deficiency related to the management of urinary and bowel needs.
A persistent foul urine-like odor was detected in the Berkshire Unit of a facility, despite cleaning efforts. The odor was noted in the hallway and inside a specific room, where a urine drainage bag with dark fluid was found under an empty bed. Staff responses varied, with some confirming the odor and others not noticing it. The Administrator acknowledged the issue and mentioned a thorough cleaning had been done, but a mild odor persisted.
A resident with no cognitive impairment and multiple diagnoses, including Ataxia and Dementia, developed a skin rash on her chest and arms, believed to be caused by wearing the same hospital gown for several days. Despite reporting the rash to CNAs, there was no documented treatment or physician order in place. Observations confirmed the rash, and the resident stated she had not received any cream. The facility's care plan and records lacked documentation of the rash, and the Unit Manager acknowledged the absence of a physician order.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, with multiple observations of unsanitary conditions, improper food temperatures, and inadequate cleaning practices. Surveyors noted issues such as uncovered soiled trays, staff with uncovered facial beards, improper thermometer sanitization, and expired food items.
The facility failed to maintain a sanitary, orderly, and comfortable environment in multiple rooms across the B, C, and D Wings. Issues included non-functional electric beds, inaccessible nurse call bells, mold, rust, disrepair of walls, algae-covered windows, and missing floor cover strips, posing potential fall hazards. These deficiencies were confirmed during an environment tour with the Assistant Administrator and Corporate Housekeeping Manager.
The facility failed to properly store residents' medications, with multiple instances of over-the-counter and prescription medications being left unsecured in residents' rooms. Additionally, wound care supply carts on the C and D wings were left unlocked and unattended, containing resident-specific treatment medications.
The facility failed to follow the approved menu for various diets, affecting numerous residents. Essential items were not prepared or served, and no substitutes were provided. A resident with multiple diagnoses did not receive physician-ordered nectar thick prune juice due to it not being reflected on the tray ticket.
The facility failed to prepare food by methods that conserve nutritive value, flavor, and appearance for residents on special diets. Foods were prepared early and held at high temperatures until the dinner meal, negatively affecting their quality. Staff responsible for preparation was unaware of the impact of prolonged cooking and high heat holding and had not received formal training in quality food preparation standards.
The facility failed to prepare food in a proper pureed form for 10 residents with physician-ordered Pureed Diets. Observations revealed that the pureed rice had visible lumps and large pieces, and the Lunch Cook did not taste test the food for proper consistency. The surveyor requested the development of a policy to ensure proper food preparation.
A facility failed to prevent verbal abuse when a CNA was observed yelling at a resident after a trolley crash. The resident, who was cognitively intact and had multiple medical conditions, did not initially realize the yelling due to ear pain. Other staff members did not promptly assess the resident's well-being, despite recent training on abuse prevention.
A resident was found with a swollen finger and a bruise on the face, which staff failed to report and document in a timely manner. The Infection Preventionist and LPN were unaware of the bruise until pointed out by a surveyor. The resident's spouse mentioned a possible toothache but did not inform the staff earlier. The facility's documentation did not include prior notes about the bruise, leading to a delay in addressing the resident's condition and investigating the cause.
The facility failed to provide timely psychosocial assessments for a resident with disruptive behaviors, did not follow physician's orders for blood sugar monitoring for a diabetic resident, and neglected to perform timely skin assessments for a resident with a rash.
A resident with a stage 4 sacral pressure ulcer and a diabetic wound on the right heel did not receive proper wound care as per physician's orders. The Wound Care Nurse (WCN) failed to apply collagen powder and did not follow infection control protocols, such as changing gloves after cleaning wounds. Additionally, a Certified Nursing Assistant (CNA) did not wear a gown as required, and the resident was found wearing two briefs.
A facility failed to ensure proper hand hygiene and infection control during perineal and Foley catheter care for a resident. The CNA did not change gloves, sanitize hands, or change the rinse water after the resident had a bowel movement, leading to cross-contamination risks. Interviews confirmed that the facility's policies were not followed.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from facility staff, resulting in unmet care needs for those individuals.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. The report does not specify the particular medical history or condition of the resident at the time of the deficiency, nor does it detail the specific treatment or care that was not provided as ordered.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the care provided to residents requiring assistance with bowel and bladder management.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received the necessary respiratory care, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Medication Administration Errors Due to Failure to Follow Physician Orders
Penalty
Summary
The facility failed to follow physician orders for medication administration for two of four sampled residents during a medication administration observation, resulting in a medication error rate of 7.41%. For one resident with COPD and a BIMS score indicating cognitive intactness, a LPN administered inhaled medications via nebulizer but did not instruct the resident to rinse her mouth after treatment, as specifically required by the physician's order for Budesonide. The omission was confirmed by the Director of Nursing upon review of the order and observation of the medication pass. In a separate incident, another cognitively intact resident was ordered to receive Sodium Zirconium Cyclosilicate mixed with 8 ounces of water for hyperkalemia. The LPN administering the medication used a cup that only held 4 to 5 ounces, as the facility had run out of 8-ounce cups and had not yet distributed newly received stock. Multiple staff confirmed that only smaller cups were available on the medication carts at the time, and the Central Supply clerk acknowledged not considering alternative sources for the correct cup size. The DON verified that the medication was not mixed according to the physician's order.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These lapses were observed during the survey and contributed to the cited deficiency.
Persistent Urine Odor in Berkshire Unit
Penalty
Summary
The facility failed to maintain a clean environment free of offensive odors in the Berkshire Unit, as evidenced by a persistent foul urine-like odor. During a tour of the unit, a strong urine odor was detected in the hallway between specific rooms and inside one of the rooms. Despite cleaning efforts by a housekeeper, the odor persisted. The housekeeper, who required translation assistance, confirmed the presence of urine in the bathroom of the affected room. The Housekeeping Director also confirmed the strong odor during a side-by-side observation. Further investigation revealed a urine drainage bag with a small amount of dark fluid under an empty bed in the room, which was picked up by the District Housekeeping Manager. Interviews with staff members provided mixed responses, with one LPN not noticing the odor and another confirming its presence in the hallway. The facility's Administrator acknowledged awareness of the odor issue and mentioned that a thorough cleaning had been conducted, although a mild odor remained later in the day.
Failure to Identify and Treat Resident's Skin Rash
Penalty
Summary
The facility failed to identify and treat a resident's skin redness/rash, which was observed on the resident's chest, right upper arm, and left upper arm, with no documented treatment in place. The resident, who had diagnoses including Ataxia, Dementia, Anxiety Disorder, Chronic Kidney Disease, and foot pain, was admitted to the facility with no cognition impairment. The resident required supervision or assistance for daily activities, including personal hygiene and dressing. During an interview, the resident revealed wearing the same hospital gown for 2-3 days due to a lack of gowns, which she believed might have caused the rash. The resident reported the rash to CNAs but was unsure if the nurse was informed. Observations confirmed the redness and itching, and the resident stated she had not received any cream for the rash. The resident's active care plan, medication, and treatment administration records lacked documentation related to the skin redness/rash. There was no physician order or nursing progress notes addressing the issue. Staff interviews revealed that the CNAs were aware of the rash and had informed the nurse, but the nurse did not notice the rash during a previous shift. The Unit Manager confirmed the absence of a physician order and stated she would contact the physician for an order after observing the rash. The Director of Nursing was informed of the findings during the survey.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During multiple tours, surveyors observed numerous deficiencies, including uncovered soiled resident food trays, staff with uncovered facial beards, improper sanitization of digital food thermometers, and deeply grooved cutting boards with black mold. Additionally, juices and cottage cheese were not held at the required temperatures, and food transportation carts were heavily soiled. The Victory reach-in refrigerator was found to be in disrepair, rust-laden, and lacking an operational thermometer. Shelving and juice dispensing equipment were also noted to be unsanitary, and commercial can openers and blenders were found with dried food matter and stagnant water, respectively. The dish machine and various food preparation surfaces were not properly cleaned, and expired food items were found in the walk-in refrigerator and freezer, including non-pasteurized raw eggs with black mold, expired cottage cheese, Greek yogurt, and prepared foods. Further observations revealed that the facility's chemical testing of cleaning cloth buckets and 3-compartment sinks did not meet regulatory requirements for sanitizing chemicals. During meal observations, hot and cold foods were not held at the required temperatures, and staff repeatedly failed to properly sanitize thermometers between food items. Specific temperature violations included baked eggs, orange juice, milk, ground beef brisket, chopped chicken tenders, California blend vegetables, apple pie, gefilte fish plates, diced turkey plates, sliced turkey plates, tuna fish plates, buttered noodles, and pureed meatballs. Surveyors had to intervene multiple times to prevent the serving of improperly held foods. The facility's food service director and staff demonstrated a lack of adherence to food safety protocols, including the improper use of cleaning and sanitizing materials, failure to maintain appropriate food temperatures, and inadequate cleaning of food preparation and storage areas. These deficiencies were observed over several days and involved multiple staff members, indicating systemic issues within the facility's food service operations.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to provide necessary housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment in multiple rooms across the B, C, and D Wings. Specific deficiencies included an electric bed in the B Wing that was not working, preventing staff from positioning a resident for assistance with feeding. In the C Wing, several rooms had issues such as nurse call bell cords being wrapped around bed frames, making them inaccessible to residents, large black mold areas on bathroom ceiling tiles, dust-laden O-2 concentrator filters, rusted portable toilet commode seats, heavily rusted bed frames, and disrepair of bathroom and room walls. Additionally, room windows were covered in green algae, and personal hygiene items were improperly stored on top of paper towel dispensers. A bed rail was also found unattached and on the floor in one room. Hallway entry floor cover strips were missing in multiple rooms, posing potential fall hazards. In the D Wing, a nurse call light was wrapped around a bed frame, making it unreachable for the resident. These findings were observed during initial resident/room screenings and an environment tour conducted by the facility's Assistant Administrator and Corporate Housekeeping Manager. The issues were confirmed and discussed with the facility's administration, highlighting a significant lapse in maintaining a safe, clean, and comfortable environment for residents. The deficiencies were noted in specific rooms and common areas, indicating a widespread problem across multiple wings of the facility.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure that residents' medications were properly stored, as evidenced by multiple instances of over-the-counter and prescription medications being left in residents' rooms. For example, Resident #119 had an Aspercreme-Lidocaine roll-on bottle on her table, which she brought from home without the nurses' knowledge. Similarly, Resident #473 had a bottle of Clear-Lax powder on his table, despite being on a different prescribed laxative. Both residents lacked physician orders for self-administration and corresponding assessments or care plans in their clinical records. Additionally, Resident #474 had a white pill and a TUMS bottle with another person's name on it, which were not prescribed to him and were left unsecured in his room. Resident #475 had a bottle of 8-Hour Arthritis Pain Acetaminophen on her table, which was brought by a neighbor and left unsecured, posing a risk to her confused roommate. Resident #476 had Dry Eye Relief lubricant and Azelastine Hydrochloride nasal spray on her window sill, without physician orders or self-administration assessments in her records. These instances indicate a systemic failure to adhere to medication storage policies and procedures, as well as a lack of proper documentation and assessment for self-administration of medications. Furthermore, Resident #129 had four different prescription medications left unattended in a medication cup on her bedside table for over seventeen hours. The medications were not removed until after surveyor intervention, and there was no self-administration assessment in her records. Additionally, the facility failed to secure wound care supply carts on the C and D wings, which contained resident-specific treatment medications and other supplies. These carts were left unlocked and unattended, accessible to staff, residents, and visitors. The facility's policy on medication labeling and storage was not followed, and staff members acknowledged the deficiencies when interviewed by surveyors.
Failure to Follow Approved Menu and Dietary Orders
Penalty
Summary
The facility failed to follow the approved menu for various diets, including Regular Diets, Mechanical Altered Chopped Diets, Mechanical Altered Ground Diets, and Pureed Diets, affecting a significant number of residents. During observations on 04/07/24 and 04/08/24, it was noted that essential items such as dinner rolls and [NAME] bread were not prepared or served, and no substitutes were provided. Interviews with the lunch cook revealed that the approved menu was not available, leading to incorrect meal preparation and service. Additionally, the facility's diet census confirmed the number of residents affected by these dietary lapses. Resident #7, who has multiple diagnoses including Alzheimer's Disease, Dysphagia, and Diabetes Mellitus, did not receive the physician-ordered nectar thick prune juice during breakfast on 04/08/24. Staff interviews confirmed that the prune juice order was not reflected on the tray ticket, resulting in the resident not receiving it. The Dietary Supervisor acknowledged that if an item is not on the tray ticket, it would not be served to the resident, indicating a systemic issue in meal preparation and service documentation.
Deficiency in Food Preparation for Special Diets
Penalty
Summary
The facility failed to prepare food by methods that conserve nutritive value, flavor, and appearance for residents on physician-ordered pureed, mechanically altered chopped, and mechanically altered ground diets. During an initial kitchen/food service observation tour, it was noted that foods were being prepared early in the day and held at high temperatures until the dinner meal. Specifically, approximately 40 pounds of green beans were observed boiling and breaking apart from overcooking, and a full steam table-sized pan of baked vegetarian ziti and vegetable burgers were fully cooked and held in the oven at high temperatures from 10 AM until the 4:30 PM dinner tray line start time. Staff B, responsible for the preparation, stated that the foods are cooked early to be able to puree, chop, and ground them for mechanically altered diets and was unaware that prolonged cooking and high heat holding would negatively affect the foods' nutritive value, appearance, and palatability. Staff B also mentioned not having received formal training by the facility for quality food preparation standards. A review of the facility's diet census revealed that 10 residents had physician-ordered pureed diets, 24 residents had physician-ordered mechanically altered chopped diets, and 3 residents had physician-ordered mechanically altered ground diets. The deficiency was identified through observation, interview, and record review, indicating a systemic issue in the facility's food preparation process that affected the quality of meals provided to residents with specific dietary needs.
Failure to Prepare Proper Pureed Food
Penalty
Summary
The facility failed to prepare food in a proper pureed form to meet the needs of 10 residents with physician-ordered Pureed Diets. During an observation of the lunch meal in the main kitchen, the surveyor noted that the pureed rice had visible lumps and large pieces of rice, which did not meet the required smooth, homogenous, and pudding-like texture. A taste test conducted by the surveyor and the Food Service Director confirmed the presence of large lumps and pieces of rice in the pureed mixture. The surveyor requested that the pureed rice mixture not be served to residents on pureed diets and to puree the rice until the proper consistency was achieved. An interview with the Lunch Cook revealed that she did not taste test pureed food for proper consistency and was unaware of the risks of choking or aspiration for residents with swallowing deficiencies and dysphagia. The facility's Diet Census indicated that there were 10 residents with physician-ordered Pureed Diets, including two sampled residents. The surveyor requested that the Food Service Director and the facility's Registered Dietitian develop a policy to ensure that foods are properly prepared for all meals.
Failure to Prevent Verbal Abuse
Penalty
Summary
The facility failed to prevent verbal abuse towards a resident by a staff member. The incident involved a Certified Nursing Assistant (CNA) who was observed yelling at a resident after a trolley containing used wares crashed. The CNA accused the resident of intentionally rolling in front of the trolley. The resident, who was cognitively intact and had a history of multiple medical conditions, did not initially realize the CNA was yelling due to ear pain and ringing from the crash. The resident later confirmed that the trolley had run into him and that he had not moved intentionally. Interviews with other staff members revealed that they were aware of the crash but did not immediately check on the resident's well-being. A Licensed Practical Nurse (LPN) and a Registered Nurse (RN) both admitted to hearing the crash and seeing the aftermath but did not promptly assess the resident. The LPN consoled the resident only after the surveyor had checked on him, while the RN was preoccupied with medication and did not perform an immediate assessment. The facility's policy on abuse prevention and response was reviewed, indicating that verbal abuse includes yelling or hovering over a resident with the intent to intimidate. Despite an in-service training on abuse recognition and response conducted shortly before the incident, the staff's actions demonstrated a failure to adhere to these guidelines. The incident highlights a lapse in the facility's efforts to prevent and address verbal abuse, as well as a lack of immediate and appropriate response to potential harm to the resident.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin in a timely manner for a resident reviewed for skin discoloration. During an observation, the resident was found yelling and crying out about hand pain, with a swollen right ring finger and a red purplish area on the left side of the mouth. The Infection Preventionist initially did not notice the bruise on the resident's face and only became aware after the surveyor pointed it out. The CNA reported the redness on the resident's back but did not mention the bruise on the face, and the LPN assigned to the resident was also unaware of the bruise until it was pointed out by the surveyor. The resident was unable to recall what happened, and the spouse mentioned a possible toothache but did not inform the staff earlier. The facility's documentation did not include any prior notes about the bruise on the resident's face before the surveyor's observation. The incident was not reported to the proper authorities in a timely manner, as the staff failed to document and communicate the bruise on the resident's face promptly. The Infection Preventionist and the Director of Nursing conducted assessments and contacted risk management, the police, and social services only after the surveyor's intervention. The resident's spouse was also informed later, and it was noted that the resident is on anticoagulant medication, which could cause easy bruising. The lack of timely reporting and documentation of the injury led to a delay in addressing the resident's condition and investigating the cause of the bruise.
Failure to Provide Timely Assessments and Follow Physician Orders
Penalty
Summary
The facility failed to provide timely psychosocial assessments for a resident with disruptive yelling behaviors. Resident #104, who has severe cognitive impairment and a history of depression and dementia, exhibited frequent yelling and combative behavior. Despite the care plan's interventions to address these behaviors, staff did not effectively manage or assess the resident's needs, leading to ongoing disturbances for other residents. Interviews with staff and other residents confirmed the disruptive nature of Resident #104's behavior and the lack of effective intervention from the facility's staff. The facility also failed to follow physician's orders regarding blood sugar monitoring for Resident #323, who has Type 2 Diabetes Mellitus. The resident experienced multiple instances of blood glucose readings over 400, which were not reported to the physician as required. This oversight was confirmed through interviews with staff and a review of the resident's medical records, which showed no documentation of physician notification for the high blood sugar levels. Additionally, the facility did not perform timely skin assessments for Resident #71, who complained of buttock pain. Despite the resident's complaints and visible signs of a rash, staff did not promptly assess or report the condition to the physician. Observations and interviews revealed that the resident had a fungal rash that required medical attention, which was not addressed in a timely manner by the facility's staff.
Failure to Provide Proper Wound Care and Follow Infection Control Protocols
Penalty
Summary
The facility failed to ensure that a resident received wound care consistent with professional standards of practice. Resident #30, who had multiple diagnoses including a stage 4 sacral pressure ulcer and a diabetic wound on the right heel, did not receive proper wound care as per the physician's orders. The physician's order to cleanse the sacral wound with normal saline solution and apply collagen powder and calcium alginate was discontinued in error by the Wound Care Nurse (WCN) on 03/05/24. This error led to the omission of collagen powder during wound care observations on 04/09/24, despite the Wound Care Specialist's (WCS) plan indicating its necessity for the treatment of the sacral wound. During wound care observations, the WCN did not follow proper infection control protocols. The WCN failed to change gloves after cleaning the wounds before applying new dressings, which is a critical step in preventing infection. Additionally, the Certified Nursing Assistant (CNA) assisting with the care did not wear a gown as required, and the resident was found to be wearing two briefs, which is not standard practice. The WCN also did not address a fungal rash observed on the resident's bottom and buttocks during the wound care session. Interviews with the staff revealed a lack of awareness and adherence to the care plan and wound care protocols. The Director of Nursing (DON) acknowledged that the WCN missed a step by not changing gloves after cleaning the wound. The WCN admitted to discontinuing the physician's order in error and not applying the collagen powder during the wound care observation. The WCS confirmed that the treatment plan included the application of collagen powder and calcium alginate, which was not followed during the observed wound care session.
Inadequate Hand Hygiene and Infection Control During Perineal and Foley Catheter Care
Penalty
Summary
The facility failed to ensure appropriate hand hygiene, care, and cleanliness to avoid cross-contamination during perineal and Foley catheter care for a resident. The deficiency was observed during a care procedure for a resident with multiple diagnoses, including dementia and neuromuscular dysfunction of the bladder. The resident was noted to have a bowel movement during the procedure, but the CNA did not change gloves, sanitize hands, or change the rinse water after cleaning the feces before continuing with the perineal and Foley catheter care. The CNA, assisted by another CNA, initially washed their hands before beginning the care. However, the CNA did not allow the resident to test the water temperature and proceeded with the care without changing gloves or the rinse water after the resident had a bowel movement. The CNA continued to clean the resident's perineal area and Foley catheter tubing with the same gloves and water, only changing gloves and sanitizing hands before drying the resident's perineal area. Interviews with the CNA, a Registered Nurse/Unit Manager, and the Director of Nursing confirmed that the CNA should have changed gloves, sanitized hands, and changed the rinse water after the resident had a bowel movement. The facility's policies on perineal care and infection control were not followed, leading to the observed deficiency in care for the resident.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
