Luxe At Wellington Rehabilitation Center The
Inspection history, citations, penalties and survey trends for this long-term care facility in Wellington, Florida.
- Location
- 10330 Nuvista Avenue, Wellington, Florida 33414
- CMS Provider Number
- 106091
- Inspections on file
- 32
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Luxe At Wellington Rehabilitation Center The during CMS and state inspections, most recent first.
Surveyors found that the facility failed to follow physician orders and provide timely care in several cases: a resident did not receive ordered IV antibiotics for multiple days after an ID consultant extended therapy; another resident’s left leg skin tear lacked ongoing assessment and physician-ordered wound care, with the same dated dressing left in place for days; and two residents on Metoprolol had missing or inaccurate BP/HR documentation and repeated administration of the drug despite ordered hold parameters for low blood pressure or heart rate.
A resident with a history of stroke and hemiparesis did not receive Lactulose as prescribed due to an LPN administering an incorrect dose from a bottle labeled for another resident and failing to reorder the medication in a timely manner.
A resident with severe cognitive impairment and multiple medical conditions experienced a significant decline, including unresponsiveness, refusal of medications, and not eating. Staff did not promptly recognize or escalate the change in condition, resulting in delayed assessment and transfer to the hospital, where the resident was diagnosed with a CVA and admitted to the ICU.
A resident admitted for post-acute care with a diagnosis of atrial fibrillation did not receive the prescribed anticoagulant Eliquis, despite multiple provider notes and hospital records indicating its necessity. The medication was neither ordered nor administered during the resident's stay, and this oversight was not identified by the clinical team or pharmacist. The resident was later hospitalized with bilateral pulmonary embolism, revealing the failure to provide care according to professional standards.
Surveyors identified that multiple residents and their families experienced significant barriers to communication and a lack of staff presence, including difficulty reaching staff by phone, infrequent staff visits to resident rooms, and inability to contact social services. These issues affected residents with both mild cognitive impairment and intact cognition, and were observed during routine facility operations.
A resident admitted after back surgery with an indwelling urinary catheter did not receive appropriate care to assess or remove the catheter. The facility's records lacked documentation of any attempt to conduct a voiding trial or a urinary consult, despite the resident's cognitive ability and communication that the catheter was meant to be removed shortly after admission. The catheter remained in place until a follow-up appointment, highlighting a lapse in the facility's process.
A facility failed to change a resident's midline IV dressing as ordered, leading to a deficiency. The resident had a midline catheter placed with orders for dressing changes every Tuesday and as needed. However, the dressing was only changed on specific dates, and an observation revealed a loose dressing with a label from the technician who inserted the line. The Unit Manager confirmed the oversight, acknowledging that nurses should have noticed the need for a new dressing.
The facility staff failed to adequately monitor and document the care of two residents who experienced significant changes in condition, leading to hospitalization. One resident with chronic hematuria was found unresponsive with profuse bleeding, while another resident exhibited confusion and lethargy without proper follow-up on ordered tests. Additionally, a third resident's skin condition was not properly assessed or documented, indicating deficiencies in the facility's care processes.
A facility failed to properly secure a urinary catheter for a resident, leading to potential complications. During care, the catheter was not anchored, causing discomfort due to pulling. The catheter's securement device was not attached, and a blue clamp was not used. Despite intervention to minimize pulling, the catheter remained unsecured, contrary to the resident's care plan for catheter management.
The facility failed to ensure nurses demonstrated competency in medication administration, affecting two residents. One resident received medications without required blood pressure monitoring, while another was given medication despite low blood pressure readings, contrary to physician's orders. The DON confirmed these lapses.
The facility experienced staffing deficiencies, leading to delayed medication administration for a resident with Parkinson's and communication barriers for Spanish-speaking residents. Family members reported long response times to call lights and unmet basic needs, particularly during weekends and at night.
The facility failed to deliver meals on time and provide beverages of choice for three residents, leading to dissatisfaction. A cognitively intact resident reported consistently late breakfasts and lack of coffee. Another resident also experienced late meals and absence of coffee. A recently admitted resident received meals late and was not provided with preferred whole milk, despite it being documented. Staff interviews revealed a lack of awareness about these issues.
Three residents reported being treated without dignity and respect in the facility. A resident experienced pain during care and felt ignored by staff, while another faced abrupt behavior from a CNA and was left in a soiled diaper. A third resident felt disrespected by staff who rolled their eyes when she asked for help. The facility's administration acknowledged the lack of dignified treatment.
The facility failed to provide adequate communication for two residents who preferred Spanish, leading to a deficiency in care. One resident, with cognitive impairment, had no Spanish-speaking staff available, and no translation methods were used. Another resident, cognitively intact, was not offered a language line, despite limited Spanish-speaking staff. Family concerns about communication were noted.
A resident with Parkinson's Disease experienced delays in receiving prescribed medications, affecting her therapy participation due to dizziness. The facility's Medication Administration Record showed multiple instances of late administration, which was confirmed by the DON as not adhering to the prescribed time frames.
A resident's representative experienced a significant delay in receiving a refund for services not rendered after the resident's death. Despite multiple attempts to contact the facility, the refund was not processed until 188 days later, due to inaction by the new BOM and Administrator.
The facility failed to document and address grievances from two residents and their representatives, violating their rights to voice grievances without reprisal. One resident's representative sought a refund for services not rendered, while another reported dissatisfaction with care, but neither complaint was documented in the grievance log.
The facility failed to thoroughly investigate falls with major injuries for two residents. One resident with cognitive impairment and a history of falls was found with a hip fracture, and the investigation lacked documentation from all nursing staff. Another resident, cognitively intact and with a history of hip surgery, was found with a skin tear and later diagnosed with a hip fracture, but no thorough investigation was conducted. The Administrator acknowledged the deficiencies in both cases.
Failure to Follow Physician Orders for Antibiotics, Wound Care, and Antihypertensives
Penalty
Summary
The deficiency involves multiple failures to provide treatment and care according to physician orders and residents’ needs. One cognitively intact resident on IV Daptomycin for a MRSA left hip wound had an infectious disease (ID) consultant visit, after which the ID physician ordered continuation of IV Daptomycin until a specified date. The resident reported taking a photo of the written order and giving it to the nurse upon return from the appointment. Despite this, the facility’s records show no administration of the antibiotic or documented reason for non‑administration over three consecutive days, and the Unit Manager later stated she was unaware of any issue and had no explanation for why the consultant’s order was not implemented. Another resident was admitted without documented left leg skin issues, but a weekly skin assessment later documented a skin tear to the left lower leg following a fall. Subsequent weekly skin checks did not mention the skin tear, and there were no physician orders for care of the left leg wound. Over several days of observation, the same large wound dressing, dated from the day of the fall, remained on the resident’s left leg, with curled edges and a visible bloody area beneath, indicating the dressing had not been changed. The Unit Manager, when shown the dressing, agreed with the findings. The facility also failed to follow and document parameters for antihypertensive medications for two residents with hypertension. One resident had an order for Metoprolol with instructions to hold the dose for systolic blood pressure less than 100 or heart rate less than 60, yet the MAR for the month lacked any blood pressure or heart rate readings associated with the medication doses. During a medication pass, the RN held a dose based on a low blood pressure reading, but the MAR reflected a different blood pressure not taken at that time, and routine vital sign documentation did not specify times or consistently capture readings at both ordered dosing times. For another resident with multiple chronic conditions, including chronic diastolic heart failure and hypertension, Metoprolol was ordered with parameters to hold for low systolic or diastolic blood pressure or low heart rate. Review of the MAR showed multiple instances where the medication was documented as given despite diastolic blood pressures below the ordered threshold, and both the DON and an LPN later acknowledged that the medication had been administered when it should have been held.
Failure to Administer Medication as Prescribed and Ensure Timely Refills
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction and hemiparesis did not receive medication as prescribed and experienced a delay in medication refills. During a medication administration observation, an LPN prepared and administered several medications, including Lactulose, but used a bottle labeled for a different resident. The LPN stated that the resident was out of their prescribed Lactulose and that it had to be reordered. The medication was last reordered over a month prior, and the LPN admitted to only reordering it on the day of the observation. Further review revealed that the LPN administered 30ml of Lactulose, despite the physician's order specifying 15ml twice daily. The LPN initially believed the order was for 30ml, but upon checking the electronic record, confirmed the correct dose was 15ml. This resulted in the resident receiving an incorrect dose and medication from a bottle not labeled for them, as well as a lapse in timely medication refills.
Failure to Timely Respond to Resident's Change in Condition Resulting in Hospitalization
Penalty
Summary
Facility staff failed to protect a resident from neglect by not responding in a timely manner to a significant change in the resident's condition. The resident, who was severely cognitively impaired and had multiple diagnoses including dysarthria following cerebral infarction, heart failure, and atrial fibrillation, was admitted for post-acute care. On the morning following admission, documentation indicated the resident was alert and responsive, but by the next day, staff observed that the resident was not opening her eyes, was not eating, and was refusing medications. Despite these changes, there was a lack of prompt and thorough assessment and escalation by nursing staff. Throughout the morning and early afternoon, the resident remained unresponsive to verbal stimuli, did not eat breakfast or lunch, and did not take her scheduled medications. The primary CNA reported these changes to the nurse, but the nurse assumed the resident was tired and did not immediately escalate the situation. The PA was not notified of the resident's condition until the afternoon, and the unit manager was unaware of the resident's status until late in the day. When the resident was finally assessed by multiple nurses, she was found to be nonverbal, with abnormal pupil response and froth in her mouth, prompting an emergency transfer to the hospital. Upon arrival at the hospital, the resident was admitted to the ICU with a diagnosis of cerebrovascular accident (CVA) and had a Glasgow Coma Scale score of 8, indicating a coma. The facility's failure to recognize and respond to the resident's change in condition in a timely manner resulted in a delay in necessary medical intervention and transfer to a higher level of care.
Failure to Administer Prescribed Anticoagulant for Resident with Atrial Fibrillation
Penalty
Summary
A deficiency occurred when a resident admitted for post-acute care with a diagnosis of atrial fibrillation (Afib) did not receive the prescribed anticoagulant medication, Eliquis, as indicated in her hospital discharge records and multiple provider notes. Despite documentation from the hospital and repeated references in progress notes by nurse practitioners, physician assistants, and physicians that the resident was to be on Eliquis for Afib and deep vein thrombosis (DVT) prophylaxis, there was no corresponding physician order or administration of Eliquis during the resident's stay at the facility. The March Medication Administration Record (MAR) confirmed that Eliquis was never given, and the medication was not listed in the facility's physician orders. The resident's care plan acknowledged her altered cardiovascular status, including Afib, hypertension, and hyperlipidemia. Hospital records prior to admission to the facility indicated that Eliquis was to be restarted after stopping heparin, and the resident was cleared for discharge with instructions for follow-up related to paroxysmal atrial fibrillation. Despite this, the facility failed to ensure the continuation of Eliquis therapy, and the oversight was not identified by the pharmacist during a medication regimen review or by the clinical team, who continued to document that the resident was on Eliquis based on previous notes rather than verifying actual orders and administration. The deficiency became evident when the resident experienced a syncopal episode with hypoxia during occupational therapy, leading to her transfer to the hospital. Hospital records from this subsequent admission revealed a diagnosis of bilateral pulmonary embolism, for which a mechanical thrombectomy was performed. Interviews with facility staff confirmed that the absence of Eliquis was not recognized, and documentation errors perpetuated the assumption that the resident was receiving the medication.
Failure to Ensure Resident Dignity and Communication
Penalty
Summary
Surveyors found that the facility failed to honor residents' rights to a dignified existence and effective communication for three of four sampled residents. During a 45-minute observation on the second floor, no staff members were present at the nurses' station or visible on the unit, which housed 40 residents. Interviews revealed that one resident's spouse was unable to contact facility staff by phone and rarely saw nurses or CNAs during visits. Another resident's spouse reported minimal staff presence in the resident's room, difficulty obtaining assistance, and a lack of follow-up from the front desk. Additionally, a resident expressed frustration at being unable to reach social services by phone, despite repeated attempts and being transferred by the front desk without success. Record reviews indicated that the affected residents included individuals with mild cognitive impairment following a cerebrovascular accident, as well as residents with intact cognition, one of whom was admitted for aftercare following joint replacement surgery. The administrator acknowledged receiving frequent messages from residents and families and noted that the social worker was off on the day in question, but these explanations did not address the observed lack of staff presence and communication barriers experienced by residents and their representatives.
Failure to Assess and Remove Indwelling Urinary Catheter
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter. The resident was admitted to the facility following back surgery, during which a Foley catheter was placed. The hospital discharge instructions did not include any information regarding the catheter, and there was no documentation of an attempt to remove it. Upon admission to the facility, the resident's records indicated the presence of the catheter but lacked any assessment or rationale for its continued use. The facility's records did not document any attempt to conduct a voiding trial or a urinary consult, which are standard procedures to determine if the catheter is still necessary. The resident, who was cognitively intact, expressed to the facility staff and doctors that the catheter was intended to be removed shortly after admission. However, the facility did not act on this information, and the catheter remained in place until the resident's follow-up appointment, where it was noted that the catheter should have been removed two to three days post-admission. The First Floor Unit Manager confirmed that there was no documentation in the electronic record regarding an assessment or attempt to remove the catheter, indicating a lapse in the facility's process to ensure catheters are not retained longer than necessary.
Failure to Change IV Dressing as Ordered
Penalty
Summary
The facility failed to ensure proper care and services for the intravenous line of a resident, as evidenced by the lack of dressing changes as per physician orders. The resident, who was admitted to the facility with several peripheral IVs, had a midline catheter placed on October 28, 2024, with orders to change the dressing every Tuesday and as needed using sterile technique. However, the Medication Administration Record (MAR) showed that the dressing was only changed on October 29, November 5, and November 12, 2024, which did not align with the required schedule. During an observation on November 13, 2024, the midline IV access was noted to have a loose dressing with a label that had a nurse's initials not matching any current facility nurse, indicating it was from the technician who inserted the line. The First Floor Unit Manager confirmed the findings and acknowledged that the nurses, who were flushing the line twice daily, should have noticed the need for a new dressing. This oversight led to the deficiency in providing safe and appropriate administration of IV fluids for the resident.
Deficiencies in Monitoring and Documentation of Resident Care
Penalty
Summary
The facility staff failed to provide necessary care and services for two residents who experienced significant changes in condition requiring hospitalization. One resident, who had chronic hematuria and was on anticoagulant medication, was found unresponsive with profuse bleeding from the urinary catheter site. Despite initial interventions, such as starting intravenous fluids, the resident's condition deteriorated, leading to a transfer to the emergency room where the resident was pronounced dead. The staff did not adequately monitor or document the resident's condition, including vital signs and the amount of blood loss, after the change in condition was identified. Another resident, admitted for rehabilitation after knee replacement, exhibited changes in condition, including lethargy and confusion. Despite orders for STAT labs and imaging, there was no evidence that these were completed or that the resident was adequately monitored. The resident's condition worsened, leading to a transfer to the hospital where a critical white blood cell count was noted, indicating a severe infection. The staff failed to document reassessments or follow-up on the ordered diagnostic tests, contributing to the delay in appropriate care. Additionally, the facility staff failed to assess and document the resolution of a skin condition for a third resident. The resident was treated with zinc oxide ointment for redness on the buttocks, but there was no documentation of a skin assessment to determine if the condition met criteria for a pressure wound or if it had resolved after treatment. This lack of documentation and assessment highlights a deficiency in the facility's monitoring and care processes.
Failure to Secure Urinary Catheter Properly
Penalty
Summary
The facility failed to implement proper care practices to prevent excessive tension on an indwelling urinary catheter for a resident, leading to potential complications. During an observation of catheter and wound care, it was noted that the resident's catheter was not properly secured, which resulted in pulling and discomfort for the resident. The catheter was observed to have a wrinkled securement device that was not attached to the resident's skin, and a blue clamp was not in use. As the resident was turned during care, the catheter tubing pulled, causing the resident to moan in discomfort. The Unit Manager intervened by placing the catheter bag on the bed to minimize pulling, but the catheter was still not secured with a new device or the blue clamp. The resident, who was assessed as severely impaired for daily decision-making skills and had an indwelling urinary catheter due to obstructive uropathy, was at risk for injury or infection. The care plan for the resident included checking catheter tubing for patency and positioning the catheter bag to promote dignity and drainage, but these interventions were not adequately followed during the observed care.
Failure in Medication Administration and Monitoring
Penalty
Summary
The facility failed to ensure that licensed nurses demonstrated competency in medication administration and adherence to physician's orders, affecting two residents. Resident #3, admitted for rehabilitation with diagnoses including heart failure and hypertension, had physician's orders for Amlodipine Besylate and Carvedilol with specific parameters to hold the medication if the systolic blood pressure was less than 110 or heart rate was less than 60. However, the Medication Administration Record for October 2024 showed that the resident received these medications on multiple days without evidence of blood pressure monitoring, indicating a failure to follow the prescribed parameters. Similarly, Resident #2, also admitted for rehabilitation with heart failure and hypertension, had orders for Methocarbamol with instructions to hold the medication if the systolic blood pressure was less than 105 or if the resident was lethargic. Despite these parameters, the resident received the medication on two occasions with blood pressure readings below the threshold. An interview with the Director of Nursing and the Chief Nursing Officer confirmed that the staff did not document the vital signs for Resident #3 and administered medication to Resident #2 despite the prescribed parameters.
Staffing Deficiencies and Communication Barriers in LTC Facility
Penalty
Summary
The facility failed to ensure sufficient staffing, resulting in delayed medication administration for a resident with Parkinson's disease. The resident's family member reported that the resident's participation in therapy declined due to not receiving medications on time, affecting her blood pressure and causing dizziness. A review of the medication administration record revealed multiple instances where the resident's Parkinson's medications were administered late, sometimes by several hours, which was confirmed by the Director of Nursing. Additionally, there were communication issues for residents who only spoke Spanish, as there were no staff available who could communicate with them. Family members expressed concerns about the lack of Spanish-speaking personnel, despite being informed otherwise during the care plan meeting. This communication barrier, coupled with long response times to call lights, contributed to the perception of insufficient staffing, particularly at night. Numerous residents and family members voiced complaints about the facility's staffing levels, citing long wait times for assistance, unmet requests for basic needs, and inadequate supervision. Residents reported waiting for hours to have their call lights answered and to receive personal care, such as changing soiled briefs. These issues were more pronounced during weekends, with some residents experiencing distressing situations due to the lack of timely staff intervention.
Failure to Provide Timely Meals and Beverages of Choice
Penalty
Summary
The facility failed to ensure timely meal delivery and provide beverages of choice for three residents, leading to dissatisfaction and unmet preferences. Resident #18, who was cognitively intact, reported consistently receiving breakfast late, between 9 AM and 10:30 AM, and noted the absence of coffee on certain days. Observations confirmed the late delivery of breakfast trays, with one instance of breakfast being served at 9:40 AM and another at 10:30 AM. Resident #31 also reported late breakfast delivery and a lack of coffee for two days, which was usually provided with meals. Both residents expressed frustration over the delays and lack of preferred beverages. Resident #143, recently admitted and alert, also experienced late meal deliveries and a lack of coffee for two days. The resident expressed dissatisfaction with breakfast being served as late as 11:30 AM, lunch at 3 PM, and dinner at 7:30 PM. Additionally, Resident #143 preferred whole milk, which was documented on the meal ticket, but was repeatedly provided with nonfat milk instead. Despite the meal ticket clearly indicating the preference for whole milk, the facility failed to meet this dietary request. Interviews with the Unit Manager and Regional Food Service Manager revealed a lack of awareness regarding these issues, indicating a breakdown in communication and adherence to resident preferences.
Failure to Ensure Dignified Care for Residents
Penalty
Summary
The facility failed to ensure that three residents were treated with dignity and respect, as evidenced by interviews and record reviews. Resident #18, who was cognitively intact, reported that some staff members seemed indifferent to her needs. She experienced pain during care and felt that her concerns were not being addressed, as staff did not conduct regular rounds to check on her well-being. Additionally, she felt disrespected by a therapist who interrupted her meals to conduct exercises, disregarding her preferences. Resident #39, also cognitively intact, described an incident where a CNA was abrupt and disrespectful while assisting her with toileting. She also reported being left in a soiled diaper for over an hour and having to scream for assistance because the call light was out of reach. Resident #33 expressed that some staff members were disrespectful, rolling their eyes when she asked for help, which made her feel upset. The facility's administrator and social service assistant acknowledged that Resident #33 was not treated in a dignified manner.
Deficiency in Communication with Non-English Speaking Residents
Penalty
Summary
The facility failed to ensure adequate communication for two residents who were unable to speak English, leading to a deficiency in their care. Resident #29, who was admitted with diagnoses including Major Depressive Disorder and Difficulty in Walking, was documented as having a cognitive impairment and a preference for communication in Spanish. Despite this, there were no Spanish-speaking staff available to communicate with her, and no alternative communication methods, such as translation apps, were utilized by the care staff. This lack of communication left Resident #29 unable to express her needs or understand the staff. Similarly, Resident #394, who was cognitively intact and preferred to communicate in Spanish, was observed interacting with staff in English. The resident reported not being offered any communication system, such as a language line, to facilitate understanding. The family member of Resident #394 expressed concerns about the lack of Spanish-speaking personnel, despite being informed otherwise prior to admission. Interviews with facility staff revealed that there were limited Spanish-speaking nurses and CNAs available, and while a language line was supposed to be used when no Spanish-speaking staff were available, it was not being utilized effectively.
Failure to Administer Medications Timely for a Resident with Parkinson's
Penalty
Summary
The facility failed to ensure the timely administration of prescribed medications for a resident diagnosed with Parkinson's Disease, Syncope and Collapse, Orthostatic Hypotension, and Hypertension. The resident, who was cognitively intact with a BIMS score of 15 out of 15, reported running out of medications for 1-2 days on multiple occasions. This issue was corroborated by the resident's family member, who noted a decline in the resident's participation in therapy due to dizziness caused by the untimely administration of medications. A review of the Medication Administration Record revealed multiple instances where the resident's Parkinson's medications, Carbidopa-Levodopa Oral Tablet and Carbidopa-Levodopa ER Oral Tablet Extended Release, were administered late, sometimes by more than two hours. The Director of Nursing confirmed that medications should be given within one hour before or after the prescribed time, as per physician orders, but acknowledged that this was not consistently followed for the resident in question.
Delayed Refund Issuance After Resident's Death
Penalty
Summary
The facility failed to issue a refund to the representative of a resident within 30 days of the resident's death. The resident was admitted for skilled rehabilitation services but was discharged to a hospital due to respiratory distress and subsequently passed away. The representative, who had power of attorney, paid $2,550 for continued skilled services, which were not rendered due to the resident's hospital transfer and death. Despite multiple attempts by the representative to contact the facility for a refund, including phone calls and in-person visits, the facility did not process the refund in a timely manner. The Business Office Manager (BOM) and Administrator, both new to their positions, failed to follow up on the refund request. The BOM did not document the refund claim in the resident's financial record and did not pursue the matter after contacting the Regional Office. The Administrator, who was initially serving as Interim Administrator, forwarded the representative's voicemail to the business office but did not ensure the issue was resolved. The Grievance Officer was unaware of the refund request, and no grievance was filed. The refund was eventually processed 188 days after the resident's death, following the surveyor's intervention.
Failure to Document and Address Resident Grievances
Penalty
Summary
The facility failed to document and act upon grievances reported by two residents and their representatives in a timely manner, violating the residents' rights to voice grievances without discrimination or reprisal. The facility's grievance policy required all grievances to be considered and responded to, but this was not adhered to in the cases of the two residents involved. In the first case, a resident's representative, who held power of attorney, paid for continued skilled rehabilitation services after the resident's skilled services ended. However, the resident was discharged to a hospital the same night and subsequently passed away. The representative sought a refund for the services not rendered, but despite multiple attempts to contact the facility, including speaking with the Business Office Manager (BOM) and the Administrator, no refund was issued, and the grievance was not documented in the facility's grievance log. In the second case, another resident's representative reported dissatisfaction with the care provided, including the resident being left in a wheelchair for hours and not receiving timely assistance with turning off lights or addressing medical concerns. Despite these complaints, there was no documentation of the grievances in the facility's log. The facility only became aware of these issues during a follow-up call after the resident was discharged, but the grievances were still not recorded in the log.
Failure to Investigate Falls with Major Injuries
Penalty
Summary
The facility failed to thoroughly investigate falls with major injuries for two residents. Resident #2, who had multiple diagnoses including a history of falls and cognitive impairment, was found on the floor next to her bed with a hip fracture. The facility's investigation report lacked documentation from all nursing staff scheduled to care for Resident #2 on the day of the fall, and the Administrator admitted that the investigation was not properly conducted and did not verify if the care plan was followed prior to the fall. Resident #6, who was cognitively intact and had a history of hip surgery, was found on the floor in a sitting position with a skin tear and later diagnosed with a right hip fracture. The incident report for Resident #6 did not include statements from the nursing staff caring for her on the day of the incident, and no thorough investigation was conducted. The Administrator acknowledged that an investigation should have been done, especially considering Resident #6's medications that increased her fall risk. Both cases highlight the facility's failure to conduct comprehensive investigations into falls with major injuries, as required by their protocols. The lack of thorough documentation and investigation into these incidents indicates a significant deficiency in the facility's handling of fall-related events, potentially compromising resident safety and care quality.
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.
