Melbourne Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Melbourne, Florida.
- Location
- 1415 S Hickory St, Melbourne, Florida 32901
- CMS Provider Number
- 105207
- Inspections on file
- 23
- Latest survey
- March 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Melbourne Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to adhere to professional standards for food storage and sanitation, as observed during a kitchen tour. Improperly labeled and dated food items were found in the walk-in refrigerator and freezer, including leftover meats and vegetables, undated eggs, and cheese. Additionally, issues were noted in the dry storage room and with the cleanliness of the kitchen floor. The facility's policies on food storage and labeling were not followed, potentially affecting all residents consuming food prepared in the kitchen.
The facility failed to honor residents' dignity by using inappropriate labels and did not adequately support a resident's healthcare coordination needs. Staff referred to residents needing assistance with eating as 'feeders,' and a resident's Medicaid recertification was mishandled, delaying medical care and relocation plans.
The facility failed to provide a homelike environment and maintain cleanliness in the dining room and resident rooms. The dining room lacked tablecloths, centerpieces, and music, while resident rooms had issues with sticky floors, dirty air conditioning filters, and unpleasant odors. The Environmental Director acknowledged these issues and the need for better oversight of cleaning practices.
The facility did not post the required daily nursing staffing information, omitting the number and type of staff and the facility name on the Nurse Staffing Form. The Staffing Coordinator and Administrator cited company changes and uncertainty about the facility name as reasons for these omissions.
The facility failed to ensure residents performed hand hygiene before meals, as observed on multiple occasions where residents were not offered means to clean their hands before eating. Staff acknowledged the oversight, and the facility's policy emphasized the importance of hand hygiene, which was not consistently practiced.
The facility failed to conduct a medication self-administration assessment for two residents, leading to a deficiency in ensuring the safety of self-administered medications. One resident was observed with an inhaler at her bedside without a physician's order for self-administration, while another had an inhaler in her pocket with no documented assessment for self-administration. The DON confirmed that the facility's policy requires an assessment and a care plan for self-administration, which were not followed.
The facility failed to ensure accurate PASARR evaluations for two residents, leading to deficiencies in their mental health assessments. One resident's PASARR was missing diagnoses of major depressive disorder, panic disorder, and PTSD, while another's lacked the diagnosis of psychotic disorder with delusions. The Lead MDS Coordinator acknowledged these oversights, and the facility initiated a Performance Improvement Project to address the issues, but confusion remained about the accuracy of diagnoses listed in PASARR forms.
A facility failed to document a resident's blood pressure before administering Midodrine HCL, as required by the care plan. The resident, with conditions including Parkinsonism and syncope, had specific parameters for medication administration based on blood pressure readings. However, the facility did not consistently record these readings, leading to medication being given without confirming if the systolic blood pressure was within the prescribed limits.
The facility failed to provide respiratory care according to professional standards and physician orders for two residents. One resident received oxygen at a higher rate than prescribed without documented approval, while another received oxygen without a physician's order and had outdated tubing. These lapses were acknowledged by the facility's staff, indicating non-compliance with established policies.
A facility failed to ensure pharmacist recommendations were addressed by a physician for a resident at risk for falls due to psychotropic medications. The pharmacist suggested evaluating and possibly tapering Mirtazapine and Gabapentin after a fall, but these were not addressed. The DON confirmed the oversight, which was not in line with facility policy requiring physician documentation of actions taken on pharmacist recommendations.
A resident fell from her bed due to improper technique used by a CNA during incontinence care, resulting in a laceration. The facility failed to report the incident as neglect to the State Survey Agency within the required timeframe, delaying the report by 42 hours. The delay was due to the facility's practice of discussing incidents in IDT meetings held on Mondays, which postponed the recognition of the incident as reportable.
A resident with cognitive and mobility impairments eloped from a facility unsupervised, traveling 0.7 miles before being found by his son. Despite a care plan addressing elopement risk, staff failed to notice his absence for 90 minutes, and the facility's elopement protocol was not promptly activated. Interviews revealed inadequate communication and training among staff regarding residents at risk for elopement.
A resident with cognitive and mobility impairments eloped from a facility due to inadequate supervision and security measures. The resident exited through an unlocked door and wandered unsupervised for approximately two hours before being located. Staff were unaware of the resident's absence and did not follow elopement protocols promptly, failing to contact local authorities for assistance. The facility's lack of secure environment and staff training contributed to the incident.
A resident with physical and cognitive impairments exited the facility unsupervised due to ineffective elopement prevention measures. The facility's lobby doors and alerting systems were not activated, and staff were unaware of the resident's absence for about two hours. The Maintenance Director and DON were aware of the issues, but necessary revisions and implementations were delayed, leading to the resident's elopement.
Improper Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as observed during a kitchen tour. Several food items in the walk-in refrigerator were improperly labeled and dated, including leftover mechanical soft pork, sweet potatoes, corn, and mashed potatoes, which were kept beyond the facility's stated policy of three days for meat and five days for vegetables. Additionally, there were undated and open packages of hard-boiled eggs, whole eggs, tilapia fish, and fried eggs, which were discarded by the Assistant Dietary Manager. In the walk-in freezer, there were undated bags of leftover pork and Salisbury steak with frost buildup, and undated chicken tenders, all of which were also discarded. In the cook's reach-in refrigerator, there were undated stacks of American cheese slices and unlabeled tubs of leftover peaches and fruit cocktail, which were discarded as well. Further observations revealed issues in the dry storage room, where an unlabeled and undated bin contained a bag of sugar and an opened, undated bag of evaporated milk. A dirty tray held clean drinking glasses intended for resident use. Under the cook's food preparation table, three dry storage bins lined with dirty plastic bags contained flour with no indication of when it was received or opened, and a flying insect was observed near the dirty flour bin. Additionally, the kitchen floor tiles and grout had a buildup of a black substance, particularly around the floor drains. The facility's policies on food storage and labeling were not adhered to, as evidenced by the lack of proper labeling, dating, and sanitation practices, which could potentially affect all residents consuming food prepared in the kitchen.
Failure to Honor Resident Dignity and Support Healthcare Coordination
Penalty
Summary
The facility failed to honor residents' dignity by using inappropriate labels and did not adequately support a resident's healthcare coordination needs. During a lunch meal service, staff members referred to residents who required assistance with eating as 'feeders,' which was acknowledged by the Administrator as inappropriate and against the facility's policy on dignity. This labeling was observed and confirmed through staff interviews, indicating a lack of adherence to the facility's dignity policy. Additionally, the facility did not timely assist a resident with maintaining active health insurance, which affected his access to necessary medical care and his plans to move to an assisted living facility. The resident, who had intact cognition, had requested help with recertifying his Medicaid insurance in October 2024. However, the Business Office Manager failed to follow up on the recertification process, resulting in the resident losing his insurance coverage. This oversight delayed his dermatology appointments and his transfer to an assisted living facility, as his Medicaid status was crucial for these processes. The resident's medical records indicated a need for dermatology and ophthalmology referrals, which were delayed due to the insurance issue. The Business Office Manager's failure to ensure the Medicaid recertification was processed in a timely manner, along with the Social Services Director's awareness of the resident's desire to move, contributed to the resident's prolonged wait for appropriate care and relocation. The facility's policy on exercising resident rights emphasizes maintaining self-esteem and self-worth, which was not upheld in this case.
Failure to Maintain Homelike Environment and Cleanliness
Penalty
Summary
The facility failed to provide a homelike environment in the dining room and resident rooms, as observed during a survey. In the dining room, 36 residents were observed eating lunch without tablecloths, centerpieces, or music to create a homelike atmosphere. The Director of Activities acknowledged the absence of these elements and was unsure why they were not being used, despite the facility having seasonal centerpieces available. In the resident rooms, cleanliness issues were noted. Resident #13's room had dirty shoe marks, sticky floors, and a large patched area on the wall that was not repainted. Housekeeping staff used one mop head per room and did not change mop water throughout their shift, contributing to the stickiness. The Environmental Director expected fresh cleaning water to be used twice daily but acknowledged missed areas during deep cleaning. Resident #20's room had sticky floors, a brown hue on the toilet seat, and a sewer-like odor in the bathroom. The Environmental Director confirmed these issues and noted the need for better oversight of cleaning practices. Resident #62's room had gray and black debris on the floor, scratched and peeling paint, and a dirty air conditioning filter. The Environmental Director confirmed these observations and acknowledged the need for more thorough cleaning. The facility's policy stated that residents have the right to a safe, clean, comfortable, and homelike environment, but the observations indicated a failure to meet these standards.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nursing staffing hours, which should identify the number and type of nursing staff working in the facility. Observations on multiple dates revealed that the Nurse Staffing Form, located by the receptionist in the lobby, did not include this information. The Staffing Coordinator, responsible for posting the form, acknowledged that the facility name was missing and the form did not specify the number and type of staff. The Coordinator attributed this to ongoing company changes, leading to uncertainty about which company name to use. The Administrator confirmed that the facility had stopped including the facility name on the posted daily staffing sheet after receiving a call about a name change, despite the requirement for public viewing.
Failure to Ensure Hand Hygiene Before Meals
Penalty
Summary
The facility failed to establish a system for the prevention of communicable diseases by not ensuring that all residents were offered and encouraged to perform hand hygiene before meals in the dining room. On multiple occasions, residents were observed eating meals without being offered a means to clean their hands. Specifically, on March 4th, approximately 28 residents were observed eating lunch without being offered hand hygiene options, with some residents stating they were only offered a napkin. Similarly, on March 5th, residents who participated in morning exercises and snacks were not provided with hand hygiene options before lunch. Recreation Aide H and the Activities Director acknowledged the oversight, with the aide stating that residents were expected to use a sink in the dining room or be taken back to their rooms if their hands were very dirty. The Activities Director admitted that it had not occurred to her to ensure hand hygiene right before meals and planned to discuss this with the Administrator. The facility's policy on hand hygiene emphasized the importance of cleaning residents' hands and faces before and after meals, with wet wipes to be available at all times, highlighting a discrepancy between policy and practice.
Failure to Conduct Medication Self-Administration Assessment
Penalty
Summary
The facility failed to conduct a medication self-administration assessment for two residents, leading to a deficiency in ensuring the safety of self-administered medications. Resident #44, who was cognitively intact with a BIMS score of 15/15, was observed with an Albuterol Tartrate HFA inhaler on her overbed table, which she stated she used as needed. However, there was no physician order allowing her to keep the inhaler at her bedside or to self-administer the medication. Similarly, Resident #92, also cognitively intact with a BIMS score of 15/15, was found with an inhaler in her jacket pocket. Although there was a physician order for her to keep the inhaler at the bedside, there was no documented assessment for her ability to self-administer the medication. The Director of Nursing (DON) confirmed that the facility's policy requires an assessment for self-administration to be performed by nursing staff, a physician's order for self-administration, and a care plan for self-administration of drugs to be initiated. The DON acknowledged that these procedures were not followed for both residents. The facility's policy, dated 2/21/23, states that residents may self-administer medications only if the attending physician and the Interdisciplinary Care Planning Team determine they have the decision-making capacity to do so. The failure to adhere to these policies resulted in the deficiency noted in the report.
Deficiencies in PASARR Evaluations for Residents
Penalty
Summary
The facility failed to ensure accurate Preadmission Screening and Resident Review (PASARR) evaluations for two residents, leading to deficiencies in their mental health assessments. Resident #55 was admitted with multiple psychiatric diagnoses, including major depressive disorder, panic disorder, and PTSD, which were not updated in her PASARR Level I screen. The Lead MDS Coordinator acknowledged the oversight, noting that the PASARR was missing these critical diagnoses, which were only partially listed as anxiety disorder. Similarly, Resident #26's PASARR forms were incomplete, lacking the diagnosis of psychotic disorder with delusions, despite her care plan indicating impaired cognition due to psychosis and dementia. The Lead MDS Coordinator admitted to missing this diagnosis in the PASARR update. The facility had initiated a Performance Improvement Project to address these issues, but there was confusion among staff about the accuracy and completeness of the diagnoses listed in the PASARR forms. The Social Service Director was unable to confirm whether the diagnoses listed in an email were current or needed to be added to the PASARR, indicating a lack of clarity in the facility's auditing process.
Failure to Document Blood Pressure Before Medication Administration
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. The resident, who was admitted with diagnoses including Parkinsonism, anemia, syncope, and hypertensive heart disease, had a care plan that required regular monitoring of blood pressure and administration of Midodrine HCL with specific parameters. However, the facility did not consistently document the resident's blood pressure readings, which were crucial for determining whether the medication should be administered. The deficiency was identified when it was found that the resident's blood pressure was not documented on several occasions, and the medication was administered without confirming if the systolic blood pressure was within the prescribed parameters. The assigned nurse and the South Wing Unit Manager acknowledged the lack of documentation and the potential oversight in administering the medication. The Director of Nursing confirmed that the blood pressure was not recorded, and the medication was given, highlighting a lapse in following the facility's policy for administering medications safely and as prescribed.
Failure to Follow Respiratory Care Orders
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards and physician orders for two residents. Resident #35, who had a history of COPD, pulmonary embolism, and other conditions, was observed receiving oxygen at 3 liters per minute (LPM) instead of the prescribed 2 LPM. Despite the resident's claim that a pulmonologist approved the higher oxygen level, there was no documented order to support this change. The Licensed Practical Nurse (LPN) and Unit Manager confirmed the discrepancy, acknowledging that the oxygen orders were not followed. Resident #85, admitted with conditions including type II diabetes, heart failure, and chronic kidney disease, was receiving oxygen without a physician's order. The resident reported using oxygen daily, including during dialysis, and noted that the oxygen tubing was not changed as scheduled. The LPN confirmed the absence of an order for oxygen and that the tubing had not been changed in nine days. The facility's admission form incorrectly indicated no respiratory risk, despite the resident's need for oxygen and a history of congestive heart failure. The facility's policies on oxygen administration and physician orders were not adhered to, as evidenced by the lack of verification of physician orders and failure to change oxygen tubing as required. The Director of Nursing and the Administrator acknowledged these lapses, which were contrary to the facility's established procedures for ensuring safe and appropriate respiratory care.
Failure to Address Pharmacist Recommendations for Resident Medications
Penalty
Summary
The facility failed to ensure that pharmacist recommendations were addressed by the physician for a resident reviewed for unnecessary medications. The resident, who was admitted with multiple diagnoses including nontraumatic intracerebral brain hemorrhage, muscle weakness, and anxiety, was at risk for falls due to weakness and adverse effects of psychotropic medications. The pharmacist had submitted recommendations for the physician to evaluate and potentially adjust the resident's medication regimen, specifically suggesting a tapering of Mirtazapine and Gabapentin due to a recent fall. However, these recommendations were not addressed by the physician. The Director of Nursing (DON) confirmed that the pharmacist's drug regimen reviews and recommendations had not been addressed prior to her tenure and had not yet been addressed by her. The facility's policy required that any irregularities reported by the pharmacist be documented by the attending physician, indicating what actions were taken or the rationale for not making changes. The Administrator expected the DON to notify the physician and document their response in a timely manner, but was unaware that some recommendations from January had not been addressed. This oversight led to a deficiency in the facility's compliance with its own policies and procedures regarding pharmacist recommendations.
Delayed Reporting of Neglect Incident
Penalty
Summary
The facility failed to report an allegation of neglect to the relevant State Agencies within the regulatory timeframe. A resident, who was bedbound and required total assistance with activities of daily living, fell from her bed while a CNA was providing incontinence care. The CNA used improper technique by turning the resident away from her, resulting in the resident rolling off the bed and sustaining a laceration to her right temple. This incident was classified as possible neglect by the facility's Interdisciplinary Team (IDT) during a meeting held three days after the incident. The Director of Nursing (DON) was informed of the incident shortly after it occurred, but the facility did not submit an Immediate Report to the State Survey Agency until 42 hours after the allegation was made. The facility's policy requires that such allegations be reported immediately, or within 24 hours if no serious bodily injury occurred. The delay in reporting was attributed to the facility's practice of discussing incidents in IDT meetings held on Mondays, which in this case, delayed the recognition of the incident as reportable. The resident's family was notified of the fall and subsequently filed a grievance alleging negligence, which was not acknowledged by the facility until two days later. The grievance, along with the reenactment of the incident by the CNA, led the facility to decide that the incident was reportable. Despite the facility's policy and the availability of the reporting system over the weekend, the DON focused on the CNA's adherence to the resident's care plan rather than the immediate reporting requirements.
Neglect in Preventing Resident Elopement
Penalty
Summary
The facility failed to protect a resident from neglect by not implementing measures to prevent elopement. A cognitively and physically impaired resident, who was at risk for elopement, exited the facility unsupervised. The resident wandered through a parking lot, crossed a road, and traveled approximately 0.7 miles along a busy road. The facility was unaware of the resident's absence until a Registered Nurse noticed he was missing, and a search was not initiated for approximately 90 minutes. The resident was eventually found in a shopping center parking lot by his son, who informed the facility of his location. The resident had a history of dementia, diabetes, and mobility issues, requiring assistance with activities of daily living and ambulation. His care plan included interventions for potential elopement, such as monitoring for exit-seeking behavior and the use of a wanderguard. Despite these measures, the resident was able to leave the facility without staff noticing. Interviews with staff revealed that the resident frequently expressed a desire to leave and had a history of wandering, yet these behaviors were not adequately addressed or communicated among the staff. Staff interviews indicated a lack of urgency and communication in responding to the resident's elopement. The Director of Nursing was not informed promptly, and the facility's elopement protocol was not activated in a timely manner. Additionally, some staff members were unaware of the resident's appearance or the procedures for locating a missing resident, highlighting deficiencies in staff training and communication regarding residents at risk for elopement.
Removal Plan
- The resident was returned to the facility and immediately received a nursing physical assessment with no findings of injuries or identified concerns. The physician and resident representative were notified of the event.
- The Elopement Risk Alert Binder was reviewed to ensure all residents at risk for elopement had a picture and demographics in place. The affected resident remained on 1:1 supervision.
- The facility conducted a head count of all current residents; all were safe and accounted for.
- All exit doors were assessed by the Executive Director and Maintenance Director to ensure proper functioning; no issues or concerns were identified.
- Re-evaluations/review of all current residents for elopement risk was conducted.
- All door codes were changed.
- An Immediate Federal Report was filed.
- DCF (Florida Department of Children and Families) agent arrived to investigate inadequate supervision with findings unsubstantiated.
- The DON/designee reviewed elopement binders to ensure residents at risk for elopement were present and identified.
- The Executive Director/designee and DON/designee began reviews to ensure the safety and well-being related to elopement was maintained by the continued participation, evaluation, and intervention through maintaining the Quality Assurance/Performance Improvement (QAPI) process.
- Weekly audits were initiated on the components of elopement care management system with emphasis on adequate supervision. Audit findings were reported to the QAPI Committee weekly until a committee determination of substantial compliance and recommendation of monthly monitoring by the Regional Director of Clinical Operations when completing their systems review.
- French door magnetic lock system was reactivated by maintenance. The front door screamer system was assessed and found to be working properly; the volume was increased.
- Review of all residents identified at risk for elopement was completed by Unit Manager/designee for Elopement Screen, Care Plans related to wandering risk, CNAs Kardex reflective of resident status, and presence in Elopement Binders.
- The Maintenance Director contacted local electrical vendor for door alarm and nurse call system inspections; inspections were completed with no identified concerns.
- The DON/designee educated staff on: components of regulation F600 with an emphasis on abuse, neglect, and adequate supervision with posttests.
- 100% of actively working staff were re-educated in person and/or via telephone; no inactive or scheduled staff were permitted to work without prior receipt of in-person education. Any future newly hired employees were to receive the same education with orientation.
- Electrician provider was contacted for addition of wanderguard (alerting bracelet) system installation.
- 24-hour door monitors were scheduled until the wanderguard system installation completion.
- Ad Hoc QAPI attended by Medical Director, DON, and Regional President (in place of Nursing Home Administrator), and Regional Nurse Consultant was convened to review the components of ongoing elopement, the Charter Performance Improvement Plan (PIP) that included education, drills, resident evaluations, door and alarm checks, elopement risk binders placement and accuracy, french door at lobby exit magnetic lock functioning, 24-hour door monitors, new wanderguard system in place and audits completed, and systemic change and effectiveness review.
- Plans and interventions in place were determined by the facility to be effective.
Resident Elopement Due to Inadequate Supervision and Security
Penalty
Summary
The facility failed to provide adequate supervision and a secure environment to prevent the elopement of a resident who was physically and cognitively impaired. The resident, who had a history of dementia, diabetes, and mobility issues, was able to exit the facility unsupervised when an unknown staff member unlocked the door. The resident wandered through the parking lot, crossed a two-lane road, and traveled approximately 0.7 miles along a four-lane road with moderate traffic, placing him at risk for serious injury or death. The resident's medical records indicated he was at risk for elopement due to cognitive impairment, decreased mobility, and poor decision-making skills. Despite these risks, the facility did not implement adequate interventions to prevent his elopement. Staff were unaware of the resident's whereabouts for approximately two hours until his son called to inform them of his location. Interviews with staff revealed a lack of awareness and urgency in responding to the resident's absence, and the facility's elopement protocols were not followed promptly. The facility's failure to maintain a secure environment and provide adequate supervision was compounded by issues such as unlocked doors, lack of staff training on elopement procedures, and insufficient communication among staff regarding high-risk residents. The resident's elopement was not promptly addressed, and the facility did not contact local authorities to assist in the search, further delaying the resident's safe return.
Removal Plan
- The resident was returned to the facility and immediately received a nursing physical assessment with no findings of injuries or identified concerns. The physician and resident representative were notified of the event.
- The Elopement Risk Alert Binder was reviewed to ensure all residents at risk for elopement had a picture and demographics in place. The affected resident remained on 1:1 supervision.
- The facility conducted a head count of all current residents; all were safe and accounted for.
- All exit doors were assessed by the Executive Director and Maintenance Director to ensure proper functioning; no issues or concerns were identified.
- Re-evaluations/review of all current residents for elopement risk was conducted.
- All door codes were changed.
- An Immediate Federal Report was filed.
- DCF agent arrived to investigate inadequate supervision with findings unsubstantiated.
- The DON/designee reviewed elopement binders to ensure residents at risk for elopement were present and identified.
- The Executive Director/designee and DON/designee began reviews to ensure the safety and well-being related to elopement was maintained by the continued participation, evaluation, and intervention through maintaining the Quality Assurance/Performance Improvement (QAPI) process.
- Weekly audits were initiated on the components of elopement care management system with emphasis on adequate supervision. Audit findings were reported to the QAPI Committee weekly until a committee determination of substantial compliance and recommendation of monthly monitoring by the Regional Director of Clinical Operations when completing their systems review.
- French door magnetic lock system was reactivated by maintenance. The front door screamer system was assessed and found to be working properly; the volume was increased.
- Review of all residents identified at risk for elopement was completed by Unit Manager/designee for Elopement Screen, Care Plans related to wandering risk, CNAs Kardex reflective of resident status, and presence in Elopement Binders.
- The Maintenance Director contacted local electrical vendor for door alarm and nurse call system inspections; inspections were completed with no identified concerns.
- The DON/designee educated staff on: components of regulation F600 with an emphasis on abuse, neglect, and adequate supervision with posttests.
- 100% of actively working staff were re-educated in person and/or via telephone; no inactive or scheduled staff were permitted to work without prior receipt of in-person education. Any future newly hired employees were to receive the same education with orientation.
- Electrician provider was contacted for addition of wanderguard (alerting bracelet) system installation.
- 24-hour door monitors were scheduled until the wanderguard system installation completion.
- Ad Hoc QAPI attended by Medical Director, DON, and Regional President (in place of Nursing Home Administrator), and Regional Nurse Consultant was convened to review the components of ongoing elopement, the Charter Performance Improvement Plan (PIP) that included education, drills, resident evaluations, door and alarm checks, elopement risk binders placement and accuracy, french door at lobby exit magnetic lock functioning, 24-hour door monitors, new wanderguard system in place and audits completed, and systemic change and effectiveness review.
- Plans and interventions in place were determined by the facility to be effective.
Failure in Elopement Prevention Measures
Penalty
Summary
The facility's administration failed to implement effective elopement prevention measures, resulting in a physically and cognitively impaired resident exiting the facility unsupervised. On the evening of 10/26/24, the resident left through the front entrance after an unknown staff member unlocked the door. The resident wandered through the parking lot, crossed a two-lane road, and traveled approximately 0.7 miles along a four-lane road with moderate traffic. The facility was unaware of the resident's elopement until a Registered Nurse noticed the resident was missing, but a search was not initiated for approximately 90 minutes. The resident was eventually located in a shopping center parking lot after being missing for about two hours, with the facility only learning of his location when the resident's son called. The investigation revealed that the facility's lobby doors and alerting bracelet alarm systems were not activated, despite the former Nursing Home Administrator being aware of these issues since March 2024. The Maintenance Director confirmed that the magnetic lock system was not functioning properly and that the double door alarm was not utilized by staff. Partial inspections were conducted, but necessary revisions were not completed until after the elopement incident. The Director of Nursing expressed concerns about the lack of an alerting bracelet system and noted that the equipment box at the front exit was not activated. Despite being aware of the high cost, the system was not implemented, and the issue remained unresolved for several months.
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.
