Page Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Myers, Florida.
- Location
- 2310 N Airport Road, Fort Myers, Florida 33907
- CMS Provider Number
- 105864
- Inspections on file
- 29
- Latest survey
- October 28, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Page Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple mobility impairments and a history of lower extremity fractures was injured when a restorative CNA assisted with range of motion exercises in a manner not specified in the care plan. The aide provided hands-on assistance during what should have been active range of motion (AROM) exercises, resulting in a popping sound and severe knee pain. Subsequent evaluation revealed a closed fracture of the lateral tibial plateau. Staff interviews confirmed that only AROM was recommended and that aides were not trained to perform passive range of motion (PROM), indicating a failure to follow the resident's care plan.
A resident with significant mobility and cognitive impairments experienced multiple falls while attempting to use the bathroom independently. Despite care plans outlining fall prevention strategies such as regular toileting, use of call lights, and environmental safety measures, documentation showed inconsistent implementation and follow-through by staff. Gaps in providing timely assistance and unclear documentation contributed to repeated incidents.
A resident with significant mobility and cognitive impairments experienced multiple falls due to the facility's failure to consistently implement and document individualized fall prevention interventions, including timely toileting and supervision. Despite updates to the care plan after each incident, there was no evidence that key interventions, such as frequent checks and scheduled toileting, were carried out as required.
A resident with severe cognitive impairment was allegedly hit by a CNA after the resident bit the CNA during care. A Social Worker Assistant witnessed the incident and reported it to the Administrator. The facility's investigation verified the abuse allegation, leading to the CNA's suspension and reporting to authorities.
A CNA was reported to have hit a resident during care, as witnessed by a Social Worker Assistant. The CNA denied the allegation, claiming the resident was combative and bit her. The resident, who has a history of being pleasant but sometimes combative, was transferred to the memory care unit for increased supervision. The facility's investigation verified the allegation.
A resident with dementia and psychosis eloped from a facility and was found deceased after expressing paranoid behaviors and a desire to leave. Despite these signs, the facility failed to re-evaluate the resident's elopement risk or update the care plan for increased supervision. Staff observed the resident outside but did not intervene, and communication lapses contributed to the neglect. The facility's investigation did not initially find neglect, despite evidence to the contrary.
A cognitively impaired resident with a history of psychiatric conditions expressed paranoia and intent to leave the facility. Despite clear signs of distress, the facility failed to reassess the resident's elopement risk or update the care plan for increased supervision. The resident exited the facility unsupervised and was later found deceased, highlighting the severe consequences of inadequate supervision.
A resident with Bipolar disorder and paranoia expressed intent to leave the facility, believing he was under attack. Despite warnings from the resident's son and law enforcement, the facility failed to reassess the resident's elopement risk or update his care plan. The resident was later found deceased after being reported missing, highlighting deficiencies in the facility's investigation and corrective actions.
The facility failed to provide a safe, clean, and comfortable environment for residents, with deficiencies observed in all units. Issues included improperly stored bedpans and urinals, rusted and dirty faucets, unlabeled personal items, and dead insects. The ice machine and refrigerator in the memory care unit were also neglected, with expired milk and substances found. The DON acknowledged the lack of a policy for storing personal items.
The facility failed to securely store and properly administer medications, as observed during a survey. A resident had a potassium pill left on her bedside table without an order to self-administer, and another resident's Albuterol inhaler was left unattended. Additionally, pills were found on the floor in two separate locations, indicating a failure to adhere to the facility's medication administration policy.
The facility's pest control program was ineffective, as evidenced by live and dead insects found in resident rooms and common areas. Despite monthly pest control services, residents frequently reported sightings of large crawling insects, with some insects contaminating food and personal spaces. The facility's pest control policy assigns responsibility to the Maintenance Department, but there was no proactive inspection by staff to identify pest issues.
Improper Restorative Nursing Technique Results in Resident Fracture
Penalty
Summary
The facility failed to provide restorative nursing services as specified in the care plan for a resident, resulting in a fracture. The resident, who had diagnoses including necrotizing fasciitis, osteoarthritis, a previous displaced fracture of the right tibia, and bilateral foot drop, required substantial to maximal assistance for bed mobility and transfers. The care plan and therapy recommendations specified that the resident should perform active range of motion (AROM) exercises independently, with encouragement to spend less time in bed, and did not recommend passive range of motion (PROM) to be performed by restorative aides. On the day of the incident, a restorative CNA was providing range of motion exercises to the resident's lower extremities. During the session, the aide assisted the resident by lifting her right leg and bending her knee, which was not in accordance with the AROM-only recommendation. Both the resident and the aide heard a popping sound, and the resident immediately experienced severe pain. The incident was reported, and initial x-rays were negative, but subsequent evaluation by an orthopedic specialist revealed a closed fracture of the lateral tibial plateau. Interviews with facility staff, including the Director of Rehabilitation and a physical therapist, confirmed that only AROM was recommended and that restorative aides were not trained or authorized to perform PROM. The physical therapist indicated that the aide should not have had hands-on involvement during AROM, and the Director of Rehabilitation acknowledged that PROM could result in fractures, especially in residents with conditions such as osteoporosis or decreased strength. The deviation from the care plan and improper technique during restorative care directly led to the resident's injury.
Failure to Implement and Document Fall Prevention Interventions
Penalty
Summary
The facility failed to implement individualized interventions and provide adequate supervision to prevent avoidable falls for a resident with multiple risk factors, including cerebral infarction, muscle wasting, impaired mobility, and cognitive deficits. The resident experienced four falls over a short period, each time attempting to go to the bathroom independently. Despite being identified as at risk for falls and having care plans that included interventions such as keeping the call light within reach, encouraging use of the call light, providing lateral fall pads, and ensuring a safe environment, documentation showed inconsistent implementation of these interventions. There was also conflicting information regarding the resident's continence status and the frequency of toileting assistance provided. The facility's records lacked evidence that staff consistently provided timely incontinent care or regular toileting, particularly in the hours leading up to the falls. After each fall, care plans were updated with additional interventions, such as posting signs to remind the resident to call for help, using nonskid footwear, and checking the resident every 15 minutes post-fall. However, there was no documentation that these interventions were reliably implemented. Staff interviews confirmed gaps in documentation and uncertainty about whether new interventions were carried out as planned.
Plan Of Correction
Corrective action will be accomplished for those residents found to have been affected by the deficient ice. Resident #2 no longer resides at the facility. You will identify other residents having the potential to be affected by the same deficient practice. What corrective action will be taken? A resident in the facility will be re-evaluated for bowel and bladder function by August 1st, 2025, by the facility nurse management. Based on the evaluation, the resident will be placed on the proper bowel and bladder program (toileting, check and change routinely, etc.) to ensure that bowel/bladder needs are being met appropriately. The program will then be triggered in point of care for the CNA's to document on every 2 hours or as directed. Facility nurse management will review each bladder evaluation upon admission, quarterly, and during significant changes to ensure that the evaluation is completed appropriately and that the bowel/bladder program is appropriate and meets the needs of the resident. Facility IDT will review each resident with a fall for the past 3 months, ongoing, and complete an analysis as needed. The analysis will include a root cause analysis to determine the underlying factors contributing to the falls. The facility will implement a plan of action based on the root cause analysis, including interventions to prevent future falls. The nurse management will monitor the effectiveness of these interventions over the next 30 days and then weekly for 90 days. Each resident with a fall will be reviewed in the morning clinical meeting daily and in the weekly risk management meeting as part of the facility policy. The facility will also review the documentation related to the fall, including the lack of timely toileting (6 hours before the fall), and ensure that appropriate prevention interventions are in place. An interview was held with Resident #2 regarding multiple falls. Riding toileting to prevent falls should have been implemented, and the resident should have been toileted more frequently before bed, with routine checks and documentation of the 15-minute checks to ensure fall prevention. The root cause analysis was completed, and the facility will implement appropriate corrective actions based on the findings. The DON/RN will oversee the implementation of these actions and ensure ongoing monitoring. The nursing staff will be re-educated on conducting risk assessments and completing timely documentation by August 1st, 2025. They will also be trained on the importance of timely toileting and fall prevention strategies. The Director of Nursing (DON) and Regional Director of Nursing will evaluate the effectiveness of the interventions, conduct audits, and implement continuous quality improvement measures. The results of these evaluations will be reviewed by the facility administrator, and recommendations will be made for ongoing practice improvements. The Nurse V shift will monitor the implementation of the fall prevention program, and the results will be reviewed during the weekly clinical meetings. The facility will ensure that all staff are aware of and adhere to the updated policies and procedures related to fall prevention and resident safety.
Failure to Implement Individualized Fall Prevention Interventions
Penalty
Summary
The facility failed to implement individualized interventions and adequate supervision to prevent avoidable falls for a resident with multiple risk factors. The resident had a history of cerebral infarction, muscle wasting and atrophy, difficulty walking, lack of coordination, aphasia, and impaired vision. The resident was always incontinent of bladder and bowel, required assistance of two staff for transfers and ambulation, and was identified as being at risk for falls due to impaired cognition, medication use, poor safety awareness, cardiac disease, and decreased mobility. The care plan included interventions such as anticipating needs, ensuring the call light was within reach, and using fall pads, but these interventions were not consistently or effectively implemented. The resident experienced multiple falls over a short period. Each fall investigation revealed that the resident was attempting to ambulate to the bathroom independently, despite being care planned for assistance. Documentation showed inconsistent and infrequent toileting, with significant gaps between toileting times, sometimes up to 11 hours. The fall investigations did not address the lack of timely toileting or incontinent care prior to the falls. Additionally, there were inconsistencies in the bowel and bladder assessment, with conflicting information about the resident's continence status. After each fall, the care plan was updated with new interventions, such as posting signs, ensuring nonskid footwear, and implementing 15-minute checks post-fall. However, there was no documentation that these interventions, particularly the 15-minute checks, were actually implemented. The Director of Nursing was unable to provide evidence that the required checks were performed. The lack of consistent implementation and documentation of individualized interventions contributed to the resident's repeated falls.
Plan Of Correction
What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident #2 no longer resides at a facility. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? Each resident in the facility will be re-evaluated for bowel and bladder function by August 1st, 2025, by the facility nurse management. Based on the evaluation, the resident will be placed on the proper bowel/bladder program (toileting, check and change routinely, etc.) to ensure that bowel and bladder needs are being met appropriately. The program will then be triggered in the point of care for the CNA to document on every 2 hours or as directed. The facility nurse management will review each bowel/bladder evaluation upon admission, quarterly, and with significant change to ensure that the evaluation is completed appropriately and that the bowel/bladder program is appropriate and meets the needs of the resident. The facility IDT will review each resident with a fall for the past 30 days by August 1st, 2025, and each fall going forward to ensure that root cause analysis was completed and that toileting needs are being met where needed. Interventions will be implemented according to findings upon review. The facility management will also review each fall for the past 30 days by August 1st, 2025, and each fall going forward to ensure that safety checks were complete as care planned and forms are present with the root cause analysis audit. What measures will be put into place or what systematic changes will be made to ensure that the deficient practice does not recur? The nurse management team will be re-educated by the Regional Director on completing bowel/bladder evaluations, conducting root cause analysis for falls, and implementing appropriate interventions based on the root cause analysis (toileting, 15-minute checks, etc.) along with the fall prevention policy and procedure on July 24th, 2025. The nursing staff (nurses and CNAs) will be re-educated by the Staff Educator/Designee by August 1st, 2025, on completing bowel/bladder evaluations, conducting root cause analysis for falls, implementing and completing appropriate interventions (toileting, 15-minute checks), and the fall prevention policy and procedure. This re-education will include documentation of the toileting program in the point of care for the CNAs. The DON/Risk Manager will complete an audit of each resident who has a fall to ensure that the root cause analysis was completed, interventions were placed according to the root cause analysis, safety check sheets are completed as ordered, and any testing needs are being met as care planned based on bowel and bladder programs. The Nurse Management team will complete an audit each shift to monitor the documentation and the toileting programs for individual residents. How will the corrective action be monitored to ensure the deficient practice will not recur? The results of the audits will be forwarded to the Administrator and the Director of Nursing for review. The audit will then be forwarded to the monthly Quality Assurance Meeting for further review and recommendations. The audits will continue daily for 30 days and then weekly for 90 days. Each resident with a fall will be reviewed at the morning clinical meeting daily and continue to be reviewed in the weekly at-risk meeting indefinitely as part of the facility policy and procedure. Date of Compliance: August 1st, 2025
Resident Abuse Incident Involving CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse and neglect, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The incident occurred when the CNA was attempting to provide care to the resident, who was in a wheelchair. During this interaction, the resident became agitated, pushed against the CNA, and bit her. A Social Worker Assistant witnessed the CNA hitting the resident in response to being bitten. The Social Worker Assistant intervened, took the resident away, and reported the incident to the facility's Administrator. The resident involved in the incident had been admitted to the facility with diagnoses including major cognitive impairment and was residing in a secured unit for individuals with memory care needs. The resident's cognitive abilities were severely impaired, as indicated by a low score on the Minimum Data Set (MDS) assessment. Following the incident, the resident was unable to recall the event due to her advanced cognitive impairment but did report having pain in the area where she was allegedly hit. The facility's investigation into the incident included reviewing witness statements and interviewing staff. The CNA involved denied hitting the resident, claiming the Social Worker Assistant was lying. However, the facility's investigation concluded that the allegation of abuse was verified. The CNA was immediately suspended, and the incident was reported to law enforcement and Adult Protective Services. The resident's daughter, who is also her Health Care Surrogate, was informed of the incident and provided background on her mother's condition and care needs.
Plan Of Correction
This plan of correction constitutes this facility's written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law. 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; The CNA was suspended on. The CNA was terminated on. The CNA was reported to the Nurse Aide Registry on. The resident was evaluated by the Psych APRN and The Care ARPN on. New orders were received for 50mg every 6 hours as needed for or. 2. How will you identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; All residents residing in the Burroughs unit had the potential to be affected. The CNA involved worked full time on that unit only. Skin evaluations were completed on every resident on the Burroughs unit on. There were no abnormal findings indicating any type of or neglect. The CNA was suspended on and terminated on. All staff were re-educated on the policy and procedure, customer service and resident rights related to by the Nurse Management Team. This training was initiated on and was ongoing until all staff were completed. The completion date was. Knowledge verification was completed by administering a post test to all employees. The facility met with the QIO team on. The QIO team provided the facility with a De-escalation toolkit and provided training to the ADON, Staff Educator, DON and Administrator. The ADON completed the De-escalation training with all staff. This was completed to 27th, 2025. The staff remaining were removed from the schedule and the training is being offered every Tuesday as part of new hire orientation. The staff remaining will attend at that time and then may resume their normal working schedule. Knowledge verification was completed by administering a pre and post test to all employees who attended the training. 3. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur. All staff were re-educated on the policy and procedure, customer service and resident rights related to by the Nurse Management Team. This training was initiated on and was ongoing until all staff were completed. The completion date was. Knowledge verification was completed by administering a post test to all employees. The facility met with the QIO team on. The QIO team provided the facility with a De-escalation toolkit and provided training to the ADON, Staff Educator, DON and Administrator. The ADON completed the De-escalation training with all staff. This was completed to 27th, 2025. The staff remaining were removed from the schedule and the training is being offered every Tuesday as part of new hire orientation. The staff remaining will attend at that time and then may resume their normal working schedule. Knowledge verification was completed by administering a pre and post test to all employees who attended the training. Daily knowledge checks and audits will assess staff adherence to the education provided starting on. These will.
CNA Allegedly Hits Resident During Care
Penalty
Summary
A Certified Nursing Assistant (CNA) was reported to have hit a resident during an incident that occurred in the doorway of the resident's room. The Social Worker Assistant witnessed the CNA hitting the resident and immediately intervened, taking the resident away and escorting the CNA to the Administrator's office. The CNA claimed that the resident had been cursing and bit her, but denied hitting the resident. The Social Worker Assistant documented the incident, stating that she saw the CNA hit the resident and heard the resident exclaim that they had been hit with something hard. No other staff witnessed the incident, and the facility's investigation verified the allegation against the CNA. The resident involved in the incident was described as mostly pleasant but sometimes combative during care. The resident's daughter, who is also her Health Care Surrogate, mentioned that her mother had been diagnosed with a condition approximately 12 years ago and had sustained injuries that led to her admission to the facility for rehabilitation. The resident was later transferred to the memory care unit for increased supervision. Following the incident, the resident began experiencing distress, prompting the Unit Manager to contact the Advanced Practice Registered Nurse (APRN) on call.
Plan Of Correction
The CNA was suspended on and terminated on. All staff were re-educated on the policy and procedure, customer service, and resident rights related to by the Nurse Management Team. This training was initiated on and was ongoing until all staff were completed. The completion date was. Knowledge verification was completed by administering a post test to all employees. The facility met with the QIO team on. The QIO team provided the facility with a De-escalation toolkit and provided training to the ADON, Staff Educator, DON, and Administrator. The ADON completed the De-escalation training with all staff. This was completed to 27th, 2025. The staff remaining were removed from the schedule, and the training is being offered every Tuesday as part of new hire orientation. The staff remaining will attend at that time and then may resume their normal working schedule. Knowledge verification was completed by administering a pre and post test to all employees who attended the training. 3. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur. All staff were re-educated on the policy and procedure, customer service, and resident rights related to by the Nurse Management Team. This training was initiated on and was ongoing until all staff were completed. The completion date was. The training will be provided every Tuesday as knowledge verification was completed by administering a post test to all employees. The facility met with the QIO team on. The QIO team provided the facility with a De-escalation toolkit and provided training to the ADON, Staff Educator, DON, and Administrator. The ADON completed the De-escalation training with all staff. This was completed to 27th, 2025. The staff remaining were removed from the schedule, and the training is being offered every Tuesday as part of new hire orientation. The staff remaining will attend at that time and then may resume their normal working schedule. Knowledge verification was completed by administering a pre and post test to all employees who attended the training. Daily knowledge checks and audits will assess staff adherence to the education provided starting on. These will be completed by the IDT team on an ongoing random basis on all shifts. Social Services is completing daily random audits with residents and/or family members regarding and neglect.
Neglect Leads to Resident Elopement and Death
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in the resident's elopement and subsequent death. The resident, diagnosed with dementia and psychosis, exhibited paranoid behaviors and expressed a desire to leave the facility. Despite these changes in behavior, the facility did not re-evaluate the resident's elopement risk or update the care plan to ensure adequate supervision and safety measures were in place. On multiple occasions, the resident expressed fears of being under attack and requested evacuation, which was reported to the facility by the resident's son and law enforcement. However, the facility did not take appropriate action to address these concerns. Staff observed the resident outside the building but failed to intervene or notify others. Eventually, the resident was found deceased in a parking lot half a mile from the facility. Interviews with facility staff revealed a lack of communication and awareness regarding the resident's change in mental status and the need for increased supervision. The facility's investigation concluded that there was no neglect, despite evidence of the resident's expressed intent to leave and the failure to implement necessary safety measures. The Director of Nursing acknowledged that the resident's risk for elopement was not re-evaluated, and the care plan was not updated to prevent unsafe wandering and elopement.
Failure to Supervise Leads to Resident Elopement and Death
Penalty
Summary
The facility failed to recognize and adequately supervise a cognitively impaired resident, leading to a tragic outcome. The resident, who had a history of dementia, bipolar disorder, and other psychiatric conditions, exhibited new symptoms of paranoia and expressed a desire to leave the facility. Despite these clear signs of distress and intent to elope, the facility did not reassess the resident's risk for elopement or update the care plan to ensure adequate supervision. On multiple occasions, the resident communicated his fears and intent to leave, including calling his son and law enforcement, claiming he was under attack and needed evacuation. The facility was notified of these incidents, yet failed to take appropriate action to prevent the resident from leaving unsupervised. Staff members, including the DON and other nursing staff, did not communicate the resident's change in condition or the need for increased supervision, resulting in a lack of coordinated response to the resident's acute behavioral changes. Ultimately, the resident was able to exit the facility without intervention from staff, despite being seen outside by multiple employees. The lack of a clear policy on resident supervision outdoors and the failure to recognize the resident's elopement risk contributed to the resident's ability to leave the premises. Tragically, the resident was later found deceased, highlighting the severe consequences of the facility's failure to provide adequate supervision and intervention for a vulnerable resident.
Failure to Investigate Elopement Risk Leads to Resident's Death
Penalty
Summary
The facility failed to thoroughly investigate an elopement incident involving Resident #999, who was one of three residents reviewed for elopement. The resident, diagnosed with Bipolar disorder and paranoia, expressed to his son and law enforcement his intent to leave the facility, believing he was under attack. Despite these warnings, the facility did not reassess the resident's elopement risk or update his care plan with nonpharmacological interventions to ensure his safety. On the day of the incident, the resident was reported missing, and later found deceased in a parking lot half a mile from the facility. The facility's investigation into the incident was inadequate, as it did not address the failure to reassess the resident's risk for elopement following the onset of paranoid behavior. The facility's systemic corrective actions were insufficient, lacking documentation of behaviors and appropriate actions to ensure resident safety with the onset of new behaviors that could lead to elopement. The facility's Quality Assurance and Performance Improvement (QAPI) program failed to identify and address these deficiencies, creating a likelihood of unsafe wandering and elopement among cognitively impaired residents. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility did not recognize the resident as an elopement risk, despite alerts from the resident's son and law enforcement. The DON admitted that the resident's risk for elopement was not re-evaluated, and the care plan was not updated. The facility's failure to implement effective corrective actions and adequately supervise the resident contributed to the incident, resulting in a determination of isolated ongoing Immediate Jeopardy.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents across all observed units. During an initial tour, several deficiencies were noted, including improperly stored bedpans and urinals on the floor of shared bathrooms, holes and missing tiles in walls, rusted and dirty faucets, and unlabeled personal items scattered in shared spaces. Additionally, food crumbs, garbage, and rust-covered furniture were observed in resident rooms, along with dead insects and dirt accumulation in various areas, including the memory care dining room and the secured unit's refrigerator. Further observations revealed issues with the facility's equipment and storage practices. The ice machine in the memory care unit kitchen area was covered in a white film and rust, with a water collection tray and waterspout showing signs of neglect. Expired milk was found in the refrigerator, and the bottom of the freezer contained a dried yellow substance. The Director of Nursing acknowledged the lack of a policy for storing personal items, although staff had been recently educated on proper storage practices. These findings indicate a widespread failure to ensure a sanitary and homelike environment for residents.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were stored securely and administered properly, as observed during a survey. In one instance, a resident had a potassium pill left in a clear plastic medication cup on her bedside table, which she was waiting for someone to break in half. The resident did not have an order to self-administer medications, and the Unit Manager RN confirmed that the pill should not have been left with the resident. In another instance, an Albuterol Sulfate inhaler was found unattended on a bedside table while the resident was not in the room. The resident had not been assessed to self-administer the medication and had no physician order to do so. Additionally, a round orange pill was found on the floor outside a room, and a large white pill was observed on the floor of the Ford unit near the sitting room entrance. Despite being informed of the pill on the floor, a housekeeper did not attempt to remove it, and the Unit Manager RN had to be notified to remove it. These observations indicate a failure to adhere to the facility's medication administration policy, which requires medications to be administered safely and not left unattended or improperly stored.
Ineffective Pest Control Program in LTC Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a sanitary environment compromised by pests across all observed units. During an initial facility tour, live crawling insects were found in cups within the secured memory care unit, and dead insects were observed in various locations, including resident rooms and common areas. Photographic evidence was obtained to document these findings. Residents reported frequent sightings of large crawling insects, often referred to as 'waterbugs,' in their rooms and common areas, with some residents noting that insects had even contaminated their food and personal spaces. The facility's pest control policy, revised in November 2019, assigns the Maintenance Department the responsibility of coordinating pest control with an external company. Despite monthly visits from the pest control company and the application of insecticide around the building's foundation, the facility's pest sighting logs from July to December 2024 documented ongoing pest issues. Interviews with residents and staff revealed that while some residents reported pest sightings to staff, others did not, assuming staff were already aware. The Maintenance Director confirmed the presence of pest logbooks at nursing stations and stated that the pest control company reviews these logs during their visits. However, there was no proactive inspection by maintenance staff to identify pest issues within the facility.
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.
