Luxe At Lutz Rehabilitation Center (the)
Inspection history, citations, penalties and survey trends for this long-term care facility in Lutz, Florida.
- Location
- 19091 N Dale Mabry Hwy, Lutz, Florida 33548
- CMS Provider Number
- 106093
- Inspections on file
- 27
- Latest survey
- November 6, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Luxe At Lutz Rehabilitation Center (the) during CMS and state inspections, most recent first.
A resident admitted with an indwelling urinary catheter did not have timely physician orders specifying catheter size, balloon, or diagnosis, and catheter care orders were not entered until weeks after admission. Staff interviews confirmed that required orders were missing, making it impossible to verify if catheter care was provided as per standards.
The facility failed to provide continuous oxygen therapy for two residents, leading to emergency hospitalizations. One resident experienced respiratory distress due to inaccurate physician orders and lack of monitoring, while another was readmitted without reinstated oxygen orders, prompting a family member to call emergency services. Staff interviews revealed discrepancies in order transcription and administration.
The facility failed to safeguard resident medical records, allowing unauthorized access. Binders with sensitive information were left unsecured in hallways, accessible to anyone, including residents and visitors. Additionally, resident paperwork was found on nursing station counters without staff present. The DON and NHA acknowledged the accessibility issue, which violated the facility's confidentiality policies.
The facility failed to maintain proper infection control practices, with observations showing empty PPE supply carts and staff entering isolation rooms without appropriate PPE or performing hygiene. Staff interviews revealed a lack of adherence to protocols, and the DON acknowledged inconsistencies in compliance and signage, contributing to the deficiency.
A resident with multiple diagnoses, including difficulty in walking, fell in his room and sustained injuries, but the facility failed to update his care plan with new interventions. Despite the resident's dependence on staff for all ADLs and transfers, the care plan was not revised after the fall, and a Change in Condition evaluation was initiated but not completed. Staff interviews highlighted the resident's need for close supervision, yet the facility did not adhere to its policy on managing and preventing falls.
A resident experienced delays in care due to the facility's failure to implement timely care orders for a skin condition, while two other residents faced issues with medication administration. One resident's medication was inconsistently documented without explanation, and another reported not receiving medications on time, affecting her condition. Staff interviews revealed communication lapses and non-compliance with facility policies.
The facility failed to ensure effective infection control practices, including hand hygiene, sharps container management, and PPE usage. Observations revealed staff did not sanitize hands between tasks, a full sharps container was left accessible, and PPE was not used for a resident on Contact Isolation.
A facility failed to implement a care plan for a resident with CHF, Hypertension, and obesity, missing required weights and medication doses. The LPN Unit Manager confirmed the lapses, which were against facility policies, leading to the resident's hospitalization.
The facility failed to ensure resident privacy as staff and visitors were observed entering rooms without knocking. Incidents involved a CNA, a PTA, and a visitor with a dog entering rooms without waiting for an invitation, despite residents being cognitively intact and expressing their preferences. Staff confirmed that the facility's policy requires knocking and waiting for an invitation before entering resident rooms.
The facility failed to confirm the accuracy of the PASRR documentation for multiple residents, resulting in incomplete records that did not reflect all current diagnoses. The ADON admitted that the facility lacked a policy for completing PASRRs, and audits revealed significant discrepancies.
The facility failed to provide adequate personal hygiene care for two residents, both of whom were observed with unwanted facial hair despite expressing their desire for it to be removed. Staff interviews revealed inconsistencies in the provision of grooming services, and the residents' care plans indicated a need for assistance that was not met.
The facility failed to ensure that two residents received proper wound care, as multiple dressings were found unlabeled and undated. One resident had an unlabeled dressing applied after admission, and another resident had multiple undated bandages, with staff failing to follow wound care protocols.
The facility failed to maintain a medication error rate below 5%, resulting in a 25% error rate. Errors included missing medications for three residents, lack of follow-up by LPNs, and unavailability of medications in the cart. The DON acknowledged issues with medication administration timeliness and access to emergency supplies.
A facility failed to inform the physician and resident representative about missed medications and unperformed weights for a resident with serious health conditions. The resident's care plan required daily weights and specific medications, but these were not consistently administered or recorded, and the physician was not notified of the omissions.
Failure to Ensure Timely and Complete Urinary Catheter Orders and Care
Penalty
Summary
The facility failed to ensure that appropriate urinary catheter care was provided in accordance with standards of care for one resident who was admitted with an indwelling urinary catheter due to obstructive uropathy and other urological diagnoses. Upon admission, documentation confirmed the presence of a Foley catheter, but there was no corresponding physician order for the catheter, including details such as catheter size, balloon size, or the medical diagnosis necessitating its use. The treatment administration record did not reflect an order for catheter care until more than two weeks after admission, and the care plan referenced catheter care and monitoring for infection, but lacked supporting physician orders during this period. Interviews with nursing staff and the DON revealed that the facility's process required batch orders for residents with indwelling catheters, specifying catheter details and the reason for use. However, these orders were not entered at the time of admission, and staff acknowledged that without such orders, there was no way to verify if catheter care was being completed as required. The facility was unable to provide a policy regarding catheter care, and the deficiency was identified through record review and staff interviews.
Failure to Ensure Continuous Oxygen Therapy for Residents
Penalty
Summary
The facility failed to ensure continuous care and suctioning for two residents, leading to significant health issues. Resident #18, who had a history of acute respiratory failure and required continuous oxygen therapy, was not provided with accurate and active physician orders or ongoing assessments of their status and response to treatment. This oversight resulted in the resident experiencing respiratory distress and requiring emergency hospitalization. The resident's oxygen saturation was critically low, and there was a lack of documentation and monitoring of their oxygen therapy, which was not administered as per the physician's orders. Resident #12 also experienced a deficiency in care related to oxygen therapy. The resident, who had a history of respiratory failure and was dependent on supplemental oxygen, was readmitted to the facility without reinstated orders for oxygen therapy. Despite the resident's known diagnosis and historical use of oxygen, the facility failed to ensure that the necessary orders were in place upon readmission. This led to a family member calling emergency services due to the resident's need for oxygen, resulting in the resident being transferred to the hospital. Interviews with facility staff, including the DON and RNC, revealed that there were discrepancies in the transcription and administration of physician orders for both residents. The facility's electronic medical records did not accurately reflect the necessary orders for oxygen therapy, and there was a lack of monitoring and documentation in the MAR/TAR. The facility's failure to adhere to professional standards of practice and ensure proper care and suctioning for residents in need of continuous oxygen therapy resulted in significant health risks and emergency hospitalizations.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #18 no longer resides in the facility. Discharged. Resident #12 no longer resides in the facility. Discharged. On Staff LPN "D", was immediately re-educated on care and suctioning with emphasis on continuous with emphasis on accurate and active physician's orders and ongoing assessment of the resident's status and response to by the Director of Nursing. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: By a quality review was completed by Director of Nursing/designee on continuous with emphasis on accurate and active physician's orders. No additional residents were found to be affected by the alleged deficient practice. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: By, Clinical staff were educated on the components of care and suctioning with emphasis on continuous, with emphasis on accurate and active physicians orders and ongoing assessment of the resident's status and response to by Director of Nursing/Designee. By clinical staff completed competency for Recognizing Change in Condition. By, nursing staff completed RN/LPN competency checklist. Newly hired licensed nurses will be educated on the components of care and suctioning with emphasis on continuous with emphasis on accurate and active physicians orders and ongoing assessment of the resident's status and response to by Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct random audits of 5 residents with continuous daily x 4 weeks, then 5 x a week for 4 weeks then 2 x a week for 4 weeks then weekly for 1 month to ensure that accurate and active physicians orders and ongoing assessment of the resident's status and response to are in place. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Unauthorized Access to Resident Medical Records
Penalty
Summary
The facility failed to safeguard resident medical records and confidential information, leading to unauthorized access. During a tour of the 200 hall, a two-tiered rack containing white binders with room numbers and a book with resident-specific information was observed in the hallway. These binders, which included sensitive information such as resident names, dates of birth, diagnoses, and insurance details, were easily accessible to anyone walking down the hallway, including residents, family members, vendors, and visitors. Similar observations were made during subsequent tours, indicating that the binders remained unsecured and accessible. Additionally, during a tour of the nursing station, resident paperwork containing specific medical information was found on top of the nursing station counter, also easily accessible to anyone who approached. There were no staff members present at the nursing stations during these observations, further increasing the risk of unauthorized access to sensitive information. The Director of Nursing (DON) acknowledged that resident records have always been kept on the cart in the hallway and not secured behind the nurse's stations, and that papers should not be left on medication carts or counters without being turned over. The Nursing Home Administrator (NHA) confirmed that the resident records have been in the hallway since her arrival and agreed that they were easily accessible to anyone in the halls. The facility's policy on resident rights and medical records emphasizes the importance of maintaining confidentiality and safeguarding resident information, yet the observed practices did not align with these standards. The facility's failure to secure resident records and prevent unauthorized access constitutes a deficiency in maintaining the confidentiality of resident information.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Two tier racks and paperwork were relocated to a secured and confidential area for 100 and 200 hallways. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; By, a quality review was completed by Nursing Home Administrator on two tier racks and paperwork for 100 and 200 hallways were relocated to a secured in confidential area. No additional residents were found to be affected by the alleged deficient practice. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By, staff were educated on the components of Resident Records - Identifiable Information with an emphasis safeguarding resident medical records and confidential medical information in a confidential manner that would prevent unauthorized access by the Nursing Home Administrator. Newly hired staff will be educated on the components of Resident Records - identifiable Information with an emphasis safeguarding resident medical records and confidential medical information in a confidential manner that would prevent unauthorized access by the Nursing Home Administrator/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Nursing Home Administrator/Designee to conduct random audits of 4 nursing stations 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that resident medical records and confidential medical information are safeguarded in a confidential manner. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Inadequate PPE and Hygiene Practices in Facility
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were in place, particularly concerning the use and availability of personal protective equipment (PPE) and hygiene practices. Observations revealed that PPE supply carts outside rooms with isolation signs were often empty, lacking essential items such as gowns, gloves, masks, and eyewear. This deficiency was noted across multiple rooms with various precautionary signs, including contact, enhanced barrier, and droplet precautions. Staff members, including CNAs, housekeepers, and activities assistants, were observed entering these rooms without the appropriate PPE, failing to perform necessary hygiene practices, and not adhering to the required precautions. Interviews with staff members indicated a lack of awareness and adherence to PPE protocols. For instance, a CNA acknowledged knowing the resident was on contact precautions but failed to don gloves or perform hand hygiene before providing care. Similarly, a housekeeper was unaware of the droplet precautions required for a resident's room and did not know where to obtain PPE supplies. An activities assistant also failed to wear the correct PPE and did not sanitize equipment after use, despite being aware of the droplet precautions. The Director of Nursing (DON) confirmed the expectations for PPE use and acknowledged the inconsistency in staff compliance. The DON also noted the presence of different droplet precaution signs with varying instructions, which could lead to confusion among staff. Additionally, improper storage practices were observed, with non-linen items stored on clean linen carts, further compromising infection control measures.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On [date], clean linen cart on 200 unit was removed and cleaned. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], Employee "A" was immediately re-educated by the Director of Nursing on isolation precautions/proper PPE use and hygiene. On [date], Employee "G" was immediately re-educated by the Director of Nursing on isolation precautions/proper PPE use and hygiene. On [date], Central supply personnel were re-educated by the Director of Nursing on supply cart replenishment. On [date], Employee "B" was immediately re-educated by the Director of Nursing on isolation precautions/proper PPE use and hygiene. On [date], Employee "C" was immediately re-educated by the Director of Nursing on isolation precautions/proper PPE use and hygiene. On [date], staff members were immediately re-educated by the Director of Nursing on isolation precautions/proper PPE use and hygiene. On [date], Visitor education and encouragement for Control/PPE use and proper hygiene posted conspicuously in reception area by Director of Nursing. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: By [date], a quality review was completed by Director of Nursing/designee on Prevention & Control with emphasis on PPE use, PPE availability, and hygiene. Any issues identified were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: By [date], staff were educated on the components of Prevention & Control with an emphasis on use and availability of personal protective equipment (PPE) and performing hygiene by the Director of Nursing/Designee. Newly hired staff members will be educated on the components of Prevention & Control with an emphasis on use and availability of personal protective equipment (PPE) and performing hygiene by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct random audits of 5 resident rooms with transmission-based precautions 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure use and availability of personal protective equipment (PPE) and proper hygiene. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update and implement a comprehensive care plan for a resident following a fall that resulted in injuries. The resident, who was observed sitting in a wheelchair outside his room, reported stumbling and falling in his room while trying to reach his bed, which he described as being too high to sit on. This incident led to the resident sustaining an open wound on his right arm and stitches on his forehead, necessitating a hospital visit. Despite these injuries, the resident's care plan was not updated to reflect new interventions or precautions to prevent future falls. The resident was admitted with multiple diagnoses, including difficulty in walking, and was dependent on staff for all activities of daily living and transfers. A progress note indicated that the resident was found on the floor with injuries, and a Change in Condition (CIC) evaluation was initiated but not completed. The resident's care plan, which included interventions such as using the bed in the lowest position and encouraging the use of a call bell, was not revised after the fall to address the new risks and needs. Interviews with staff revealed that the resident required close supervision due to his condition, which included periods of confusion and unawareness of his surroundings. The facility's policy on managing and preventing falls emphasized the need for a resident-centered prevention plan and updating care plans based on evaluations and current data. However, the facility did not adhere to these guidelines, as evidenced by the lack of timely updates to the resident's care plan following the fall.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On , Resident #21 was immediately assessed by a licensed nurse. No concerns were noted. On post-care plan for Resident #21 was updated and intervention was implemented by Director of Nursing. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; By , a quality review was completed by Director of Nursing for post-care plan updates and interventions. No additional residents were found to be affected by the alleged deficient practice. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By , clinical staff were educated on the components of Develop/Implemented a Comprehensive Care Plan with an emphasis on post-care plan updating and intervention in timely manner by the Director of Nursing. Newly hired licensed nurses will be educated on the components of Develop/Implemented a Comprehensive Care Plan with an emphasis on post-care plan updating and intervention in timely manner by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct random audits of 5 residents with post-care plan and intervention 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that the facility is within compliance. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Deficiencies in Care Orders and Medication Administration
Penalty
Summary
The facility failed to ensure timely implementation and completion of care orders for a resident with skin issues. The resident was admitted with various diagnoses, including idiopathic conditions, and had a documented open wound that required specific treatment. However, the necessary care orders were not put in place until after the resident's second visit to an outside provider. Interviews with staff revealed a lack of communication and follow-up regarding the resident's treatment orders, resulting in a delay in care. Additionally, the facility did not administer medications appropriately for two other residents. One resident's medication administration record showed inconsistencies in the administration of sleep medication, with no corresponding nurse notes to explain the discrepancies. Another resident reported not receiving her medications on time, which affected her condition. The resident expressed frustration over the facility's repeated excuses for the medication delays, which included issues with pharmacy orders and availability. The facility's policies on medication administration and care procedures were not followed, as evidenced by the lack of documentation and communication with physicians when medications were withheld or care orders were not implemented. Interviews with staff, including the Director of Nursing, confirmed these lapses in protocol, highlighting a failure to adhere to professional standards of practice and ensure residents' needs were met in a timely manner.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 was immediately assessed by a licensed nurse. No concerns were noted. Resident #22 was immediately assessed by a licensed nurse. No concerns were noted. Resident #10 no longer resides in the facility. Discharged on (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: By , a quality review was completed by Director of Nursing/Designee on Quality of Care with emphasis on care orders put in place and completed within a timely manner. No additional residents were found to be affected by the alleged deficient practice. By , a quality review was completed by Director of Nursing/Designee on Quality of Care with emphasis on ensuring medications are administered appropriately. No additional residents were found to be affected by the alleged deficient practice. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By , clinical staff were educated on the components of Quality of Care with emphasis on care orders put in place and completed within timely manner by Director of Nursing/Designee. By , clinical staff were educated on the components of Quality of Care with emphasis on ensuring medications are administered appropriately by Director of Nursing/Designee. Newly hired licensed nurses will be educated on the components of Quality of Care with emphasis on care orders put in place and completed within timely manner and on ensuring medications are administered appropriately by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct random audits of 5 residents for care orders put in place and completed within timely manner 5x a week for 4 weeks, then 2x a week for 4 weeks and then monthly for 1 month to ensure that care orders put in place and completed within timely manner. Director of Nursing/Designee to conduct random audits of 5 residents medication administration 5x a week for 4 weeks, then 2x a week for 4 weeks and then monthly for 1 month to ensure that medications are administered appropriately. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure effective infection control practices related to hand hygiene, sharps container management, and the use of Personal Protective Equipment (PPE). Observations on the TCU unit revealed that a CNA did not sanitize or wash hands before and after delivering meal trays to multiple residents, including those in enhanced barrier rooms. This was confirmed through interviews and a review of the facility's hand hygiene policy, which mandates hand hygiene before and after direct resident contact and meal assistance. On the Lakeview unit, a medication cart with an attached sharps container was observed to be full and unable to close, making sharps accessible. This issue persisted over several hours, and the Director of Nursing confirmed that the sharps container should not have been left in that condition. The facility's policy on sharp disposal emphasizes the importance of minimizing the risk of needle sticks by ensuring proper storage of hazardous supplies. Additionally, a resident on Contact Isolation reported that staff did not wear the required PPE when entering the room. This was corroborated by observations of a Licensed Practical Nurse administering medication without donning the necessary PPE. The Infection Control Preventionist/Assistant Director of Nursing acknowledged the need for facility-wide education on proper PPE usage. Further observations in the main dining room and during lunch tray distribution revealed sporadic hand hygiene practices among staff, including a CNA who handled food without washing hands between tasks.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to implement the Comprehensive Resident-Centered Care Plan for a resident with multiple health conditions, including Congestive Heart Failure (CHF), Hypertension, and obesity. The care plan required daily weights for three days, then weekly for four months, and administration of Acetazolamide 375 mg twice a day for elevated bicarbonate levels. However, the facility did not perform the required weights on several occasions and failed to administer the medication as ordered on multiple instances. Specifically, the medication was not given on 03/29/24 and 03/30/24, and weights were not performed on 03/16/24, 03/17/24, 03/18/24, 03/20/24, and 03/27/24. The resident was admitted with acute respiratory failure and other severe conditions, and the failure to follow the care plan potentially contributed to his health deterioration and subsequent hospitalization on 04/02/2024. During an interview, the Licensed Practical Nurse (LPN) Unit Manager confirmed that the weights were not performed as ordered and that the medication was not administered due to issues with the pharmacy delivery. The facility's policies on Weight Assessment, Medication Administration, and Physician Orders were reviewed and showed that the guidelines were not followed. The LPN Unit Manager acknowledged that the assigned nurse did not document or notify the physician about the missed weights and medication doses, which was against the facility's policy. The failure to adhere to the care plan and facility policies resulted in a deficiency in the resident's care.
Failure to Uphold Resident Privacy
Penalty
Summary
The facility failed to ensure the resident's right to privacy was upheld, as staff and visitors were observed entering resident rooms without knocking. Specifically, a CNA entered a resident's room without knocking because the door was open, and she assumed it was acceptable. Another incident involved a PTA entering a resident's room without knocking and waiting to be invited in. Both residents were cognitively intact, as indicated by their BIMS scores of 14 and 15, respectively. Additionally, a visitor with a dog was observed entering multiple resident rooms without knocking, despite a resident explicitly expressing a dislike for dogs. Interviews with staff, including an LPN Unit Manager and the Acting Activities Director, confirmed that the facility's policy requires all staff and visitors to knock and wait to be invited into resident rooms. The facility's policy on Resident Rights emphasizes the importance of treating residents with respect, dignity, and privacy.
Inaccurate PASRR Documentation for Multiple Residents
Penalty
Summary
The facility failed to confirm the accuracy of the Pre-Admission Screening and Resident Review (PASRR) and to correct the document for six residents. The Assistant Director of Nursing (ADON) admitted that the facility did not have a policy and procedure for completing the PASRR. For Resident #24, the PASRR Level I did not include the diagnosis of schizoaffective disorder, and a Level II PASRR should have been completed. The ADON confirmed that the PASRR was not accurate and did not reflect all current diagnoses, including schizoaffective disorder, dementia, and anxiety disorder. Resident #2's PASRR Level I Screen was also incomplete, showing only a diagnosis of anxiety disorder and not including other diagnoses such as bipolar disorder, adjustment disorder with anxiety, major depressive disorder, and persistent mood disorder. The ADON confirmed that she only looked at physician orders to complete the PASRR and not the list of diagnoses. The Director of Nursing (DON) acknowledged that PASRRs were not complete and accurate, prompting the initiation of audits. Other residents, including Resident #43, Resident #49, Resident #238, and Resident #388, also had incomplete PASRRs that did not reflect their full range of diagnoses. For example, Resident #43's PASRR did not include anxiety, depression, or alcohol dependency, despite these being documented in the care plan and physician orders. Similarly, Resident #49's PASRR did not include depression, and Resident #238's PASRR did not include depression, anxiety, or PTSD. Resident #388's PASRR was not completed correctly, missing diagnoses of dementia and depression. The ADON confirmed these inaccuracies during interviews.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care related to personal hygiene for two residents. Resident #55, who is cognitively intact and has impairments in both upper extremities, was observed with gray facial hair on her chin on multiple occasions. Despite expressing her dislike for the facial hair and her desire for it to be removed, no assistance was provided. The resident's care plan indicated that she should receive help with personal hygiene, but staff interviews revealed inconsistencies in the provision of grooming services, including shaving, which was not offered to the resident as needed. Similarly, Resident #10, who has moderate cognitive impairment and is dependent on substantial assistance for showering, was observed with white facial hair on her chin. The resident expressed her desire for the facial hair to be removed, but no assistance was offered. Staff interviews indicated that while CNAs are responsible for grooming tasks, they only provide shaving assistance upon the resident's request, which was not effectively communicated or acted upon in this case. Both residents' records and care plans highlighted the need for assistance with personal hygiene, but the facility failed to meet these needs consistently.
Failure to Label Dressings According to Protocol
Penalty
Summary
The facility failed to ensure that two residents received treatment and care in accordance with professional standards of practice related to unlabeled dressings. Resident #340 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction. Observations revealed an unlabeled and undated dressing on the resident's left hand, which was not present upon admission. Staff interviews indicated uncertainty about the dressing's origin, suggesting it may have been applied after a blood draw, but no clear documentation or labeling was provided to confirm this. The resident's family also confirmed that the dressing was not present upon admission, indicating a lapse in proper wound care protocol adherence. Resident #389 was observed with multiple bandages on his right leg, right arm, and lower legs, many of which were not dated. The resident expressed dissatisfaction with the care, noting that the bandages often fell off. A review of the resident's physician orders and Treatment Administration Record (TAR) showed that the prescribed wound care treatments were not consistently documented as completed. Staff interviews confirmed that bandages should be labeled with the date of application, but this protocol was not followed. The Director of Nursing and Unit Manager both stated that they expect nurses to follow orders and label bandages correctly, highlighting a failure in adherence to facility protocols and professional standards of practice.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was less than 5%, resulting in a 25% error rate. During medication administration observations, multiple errors were identified for three residents. For Resident #42, the LPN did not administer Metoprolol and Eliquis due to their unavailability in the medication cart and failed to follow up with the Unit Manager or request the medications electronically. The LPN admitted to forgetting to put in the request and inform the Unit Manager, leading to the resident missing critical medications for hypertension and atrial fibrillation. For Resident #241, the LPN did not administer Calcium Carbonate as it was not available in the medication cart. The LPN moved on to the next resident without ensuring all medications were administered. The resident's MAR indicated that Calcium Carbonate and Vitamin D3 were due at 0900, but these were not given. The LPN failed to follow up on the missing medication, resulting in incomplete medication administration. For Resident #24, the RN did not have Sodium Chloride tablets available in the medication cart and refused to administer Sodium Bicarbonate as a substitute. The Unit Manager eventually obtained the correct medication from a local pharmacy. The Director of Nursing acknowledged that agency nurses do not have access to the emergency administration cart and agreed that multiple factors contribute to the timeliness of medication administration. The facility's policy states that medications should be administered safely and as prescribed, but this was not adhered to in these cases.
Failure to Inform Physician and Resident Representative of Medication and Weight Issues
Penalty
Summary
The facility failed to ensure that the physician and resident representative were informed of medications not given and weights not performed for a resident. The resident, who was admitted with multiple serious health conditions including acute respiratory failure, COPD, heart failure, and obesity, had orders for daily weights and specific medications. However, the facility did not perform the required weights on several occasions and failed to administer the medication Acetazolamide as prescribed. The medication was not given on multiple instances, and the physician was not notified of these omissions as required by the facility's policy. The resident's care plan included monitoring vital signs and weights, and notifying the physician of any significant changes. Despite this, the weights were not consistently recorded, and the medication was not administered as ordered. The Licensed Practical Nurse (LPN) Unit Manager confirmed that the weights were not performed and that the medication was not in the Emergency Drug Kit. The facility's policies on medication administration and physician orders were not followed, leading to a failure in communication and documentation regarding the resident's care.
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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