Palms At Sebring Nursing And Rehabilitation The
Inspection history, citations, penalties and survey trends for this long-term care facility in Sebring, Florida.
- Location
- 725 S Pine St, Sebring, Florida 33870
- CMS Provider Number
- 105037
- Inspections on file
- 23
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Palms At Sebring Nursing And Rehabilitation The during CMS and state inspections, most recent first.
A resident with an immunocompromised condition and other comorbidities had a standing order for daily Biktarvy, but the MAR and related notes showed multiple missed doses over two months because the medication was not available. Nursing staff documented that they were waiting for the resident or family to bring the medication from home and that insurance issues delayed refills, while several nurses and the interim DON stated the facility did not provide this antiretroviral drug due to its high cost and placed responsibility on the resident to supply it. The NHA described a process for reviewing high-cost medications and reported that a prior DON chose not to approve this medication, and the attending physician reported being informed the resident went without it for more than a week and stressed that it was a medication the resident had to take every day. The facility reported having no policy governing provision of antiretroviral medications.
Over a five-month period, the facility did not document or resolve repeated group grievances from the Resident Council regarding hydration and snack availability. Two cognitively intact residents confirmed that these concerns were discussed multiple times without any observed changes. The Activities Director admitted that group concerns were not entered into the grievance system, and the NHA was unaware of this practice, despite facility policy requiring all grievances to be documented and tracked.
The facility failed to provide the correct beneficiary notifications to three residents regarding changes in their skilled services and related coverage. Instead of issuing the required Notice of Medicare Non-coverage (NOMNC) to residents being discharged, the facility only provided the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN). This issue arose following a directive from the Administrator to use a new SNF ABN form, leading to the omission of the NOMNC for discharged residents.
The facility failed to accurately code MDS assessments for several residents, leading to discrepancies in documented care needs and diagnoses. A resident's dementia diagnosis was omitted, another's medication use was not marked, a third required more assistance than documented, and a fourth had unaddressed vision impairment. These oversights were acknowledged by staff.
The facility failed to accurately complete Level I PASRR forms for several residents, omitting key mental health and intellectual disability diagnoses. The DON acknowledged the inaccuracies, which were found in the PASRR forms of residents with conditions such as major depressive disorder, bipolar disorder, and schizophrenia. The facility's policy requires accurate PASRR completion, but this was not adhered to, leading to deficiencies in documentation.
The facility failed to develop and implement comprehensive care plans for five residents, resulting in unmet needs. A resident with tobacco use had no related care plan, while two residents requiring mechanical lifts were inaccurately assessed for partial assistance. Another resident with impaired vision lacked a care plan for vision loss, affecting her ability to identify meals. Additionally, a resident receiving hospice care had no care plan for these services. Staff interviews confirmed these deficiencies.
The facility failed to update care plans for several residents, leading to deficiencies in care. A resident with dementia had an outdated dining assistance plan, while another required more eating assistance than documented. A resident with skin impairment lacked a care plan for treatment, and a resident with aggressive behavior had no revised interventions. Additionally, a resident with a history of skin picking had no care plan updates. These issues highlight the facility's failure to adhere to its policy of updating care plans with changes in residents' conditions.
The facility failed to provide adequate care and treatment for several residents, including assistance with eating, proper assessment for transfers, timely notification of condition changes, pain management, and wound care. Residents were left unattended during meals, lacked necessary equipment like wheelchairs, and experienced delays in pain relief and wound treatment.
The facility failed to honor food preferences for several residents, leading to unmet dietary needs. A resident repeatedly requested hot tea but was not provided, while another with dental issues received food difficult to chew. A cognitively intact resident with malnutrition did not receive preferred breakfast items, and another resident noted missing condiments on meal trays. The facility's policy on food preferences was not effectively implemented.
The facility did not ensure simultaneous meal service for residents in the dining room, leading to delays and dignity issues. Observations showed residents at the same table were served at different times, with some waiting up to 21 minutes. Staff interviews revealed systemic issues with tray delivery, and the facility's policy on dignity was not upheld.
The facility failed to honor the advance directives of two residents, leading to significant deficiencies in their care. One resident, with an intellectual disability, was made to sign documents despite having a court-appointed guardian. Another resident, with cognitive impairments, was incorrectly listed as their own responsible party, despite needing a surrogate. Staff interviews revealed discrepancies and a lack of adherence to facility policies on advance directives.
The facility did not ensure the privacy of residents' health information on the East unit. Observations showed unattended medication carts with unlocked computer screens displaying medical records, and a lab book with a resident's face sheet visible at the nurses' station. Staff interviews confirmed awareness of privacy protocols, and the DON emphasized the importance of locking screens and securing papers.
A resident with multiple fractures developed new pressure wounds while in the facility, due to inconsistent wound care and preventive measures. The resident's wounds were not managed according to the facility's policy, with missed dressing changes and lack of an air mattress. The nursing staff acknowledged the challenges and deficiencies in care.
A resident was found with smoking materials in their room, unaware of the facility's smoking policy, and without a documented smoking evaluation or care plan. Additionally, razors and scissors were improperly stored in two resident rooms, with staff showing inconsistent understanding of the facility's policy on sharp objects. The facility lacked a formal policy on the prohibition of razors and scissors in resident rooms, relying instead on staff education.
A facility failed to document post-dialysis assessments for a resident with end-stage renal disease. Despite having a policy for AV-fistula-graft care, the facility did not utilize available options to record post-dialysis assessments in medical records. Nursing staff acknowledged the lack of documentation, and the DON was unaware of the documentation option.
The facility failed to complete pharmacy recommendations for two residents, leading to deficiencies in medication management. A resident with heart disease had unaddressed recommendations for Peridex solution, while another with multiple psychiatric and medical conditions had unaddressed recommendations for Diclofenac gel, Midodrine, and Calcitonin Nasal solution. The DON admitted to missing these due to falling behind, and the facility lacked a policy for handling pharmacy recommendations.
The facility failed to properly secure medications, with multiple instances of unlocked and unattended medication carts and unsecured medications in resident rooms. Observations revealed medications left on top of carts and in resident rooms, contrary to the facility's policy requiring secured storage. Interviews with the Consultant Pharmacist and DON confirmed these practices were not in compliance with established procedures.
A facility failed to follow its antibiotic stewardship protocols for a resident receiving IV antibiotics for a severe UTI. The resident's physician orders lacked end dates for Vancomycin and Cefepime, contrary to the facility's policy requiring complete antibiotic orders. The DON acknowledged the oversight, noting that all antibiotics should have an end date for proper monitoring.
A resident was issued a 30-day discharge notice citing non-payment and improved health, despite not owing money and requiring continued care. The resident, who was cognitively intact, was actually being discharged for being combative, a reason not accurately reflected in the notice. Facility staff interviews revealed inconsistencies, including the lack of a physician's signature and the resident's care plan indicating he should remain in the facility.
Failure to Provide Ordered Antiretroviral Medication Due to Cost and Availability Issues
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered antiretroviral medication to an immunocompromised resident in accordance with physician orders and the resident’s needs. The resident was admitted and readmitted with diagnoses including an immunocompromised disease, Type 2 diabetes mellitus with hyperglycemia, and major depressive disorder. The Medication Administration Records (MARs) showed an order for Biktarvy 50-200-25 mg once daily starting in October 2025. In October, the MAR reflected code “9” (other/see progress notes) on two days, but the corresponding progress notes were requested and not provided. In November, the MAR documented that Biktarvy was not administered on six separate days, again marked with code “9,” with associated order administration notes indicating the medication was not available. Progress notes for November documented multiple days when the antiretroviral medication was not given because it was not available at the facility. Nursing staff documented that the resident reported the medication had been ordered and they were waiting for it to arrive, that they were awaiting the resident to bring it from home, and that the resident had been out of the medication due to insurance changes and needed to call the pharmacy for a refill. Additional entries stated the facility was awaiting the resident to bring the medication from home, that the MD was aware, and that delivery was pending per the resident. During this period, the resident reported having had issues with insurance in the past that caused delays and missed doses of his medication. In interviews, multiple staff members, including LPNs, an RN, the interim DON, and the NHA, stated that the facility did not provide the resident’s Biktarvy because of its high cost and that the resident was responsible for supplying it. One LPN stated the resident went two days in a row without receiving Biktarvy and that the physician told her to put the medication on hold at that time, while also stating that Biktarvy and cancer medications were not provided by the facility due to cost. Another LPN and the RN confirmed that the medication was not available most of the time and that the facility did not pay for it. The interim DON reported that, upon admission, the resident was told he was responsible for the medication because it was too expensive for the facility, and did not confirm that any assistance was provided to help him obtain it. The NHA described a process in which high-cost medications are reviewed for possible alternatives and stated the prior DON decided not to approve this medication. The resident’s physician stated he had been informed the resident did not receive the medication for a week and a couple of days and that he told the facility they had to ensure the resident received it, emphasizing that it was a medication the resident could not go without and had to take every day. The facility reported having no policy for providing antiretroviral medications.
Failure to Document and Resolve Resident Council Grievances
Penalty
Summary
The facility failed to ensure that grievances raised by the Resident Council were properly documented and resolved over a five-month period. Review of Resident Council meeting minutes from June through October 2025 showed repeated discussions and requests from residents for more frequent provision of ice water and snacks. Despite these ongoing concerns, there was no documentation in the facility's grievance log reflecting these group issues, nor evidence that the concerns were formally tracked or followed up on as grievances. Interviews with two cognitively intact residents confirmed that the issues of hydration and snacks were discussed multiple times in Resident Council meetings, but no changes were observed in response to their requests. One resident reported that water refills were inconsistently provided, and another stated she had to get up at night to find water due to lack of refills. The Activities Director acknowledged that group concerns from Resident Council meetings were not entered as grievances, but rather discussed informally in Interdisciplinary Team (IDT) meetings without formal tracking or follow-up. She confirmed that if such concerns were entered as grievances, they would be tracked. The Nursing Home Administrator stated that grievances could be submitted by anyone and were logged and tracked by social services, but was unaware that Resident Council concerns were not being entered as grievances. Review of the facility's grievance policy indicated that all complaints or grievances should be documented, acted upon, and tracked, with prompt efforts made to resolve them. However, the facility did not follow its own policy regarding group concerns raised by the Resident Council, resulting in a lack of documentation and resolution for these grievances.
Failure to Provide Correct Beneficiary Notifications
Penalty
Summary
The facility failed to provide the correct beneficiary notifications to three residents regarding changes in their skilled services and related coverage. Specifically, the facility did not issue the Notice of Medicare Non-coverage (NOMNC) to residents who were discharged, instead providing only the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN). This issue was identified during a review of the Beneficiary Notice-Residents discharged within the Last Six Months form, which included 20 residents, with three randomly selected for detailed review. The residents involved were either discharged to an assisted living facility or home, and the NOMNC was not provided as required. The Social Services Director (SSD) revealed during an interview that the facility ceased issuing NOMNC forms as of a directive from the Administrator on October 31, 2024. The SSD was instructed to use a new SNF ABN form for all changes in skilled services, which led to the omission of the NOMNC for residents being discharged. The SSD acknowledged the mistake and noted that the residents were discharged from the facility, necessitating the provision of the NOMNC. The SSD also mentioned the need to treat the long-term care facility and the adjoining assisted living facility as separate entities, which was not done in this case.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in their documented care needs and diagnoses. Resident #80's MDS did not reflect a diagnosis of Non-Alzheimer's Dementia, despite medical records and physician orders indicating its presence. This oversight was acknowledged by the MDS Registered Nurse as an error. Similarly, Resident #91's MDS failed to mark the use of antipsychotic and antianxiety medications, which were prescribed and documented in the resident's physician orders. This omission was also attributed to oversight by the MDS RN. Resident #56's MDS inaccurately documented the level of assistance required for transfers, stating partial/moderate assistance when the resident actually required a mechanical lift with maximum assistance, as confirmed by the Director of Rehab. Additionally, Resident #39's MDS inaccurately reported adequate vision, despite an eye doctor's note indicating highly impaired vision and cataracts. The resident's care plan lacked interventions for vision loss, and the resident expressed difficulty in identifying meals due to her vision impairment. The Director of Nursing confirmed the expectation for accurate MDS assessments, highlighting the facility's failure to meet this standard.
Inaccurate PASRR Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure the accurate completion of Level I Preadmission Screening and Resident Review (PASRR) for nine residents out of a sample of 22. The deficiencies were identified through a review of admission records and interviews, revealing that several mental health and intellectual disability diagnoses were not marked on the PASRR forms. For instance, Resident #44's PASRR did not indicate major depressive disorder or muscular dystrophy, and Resident #55's PASRR omitted depressive disorder and epilepsy. Similar omissions were found in the PASRR forms of other residents, including those with diagnoses of bipolar disorder, schizophrenia, anxiety disorder, and conversion disorder with seizures. The Director of Nursing (DON) acknowledged the inaccuracies in the PASRR forms during an interview, stating that she was responsible for reviewing and ensuring the accuracy of these forms upon a resident's admission. The DON confirmed that the PASRRs for residents #5, #33, #39, #44, #55, #56, #91, and #94 were incorrect. The facility's policy requires that all admissions have the appropriate PASRR completed, and the DON is expected to update the PASRR if a resident receives a new diagnosis. The facility's policy outlines that the Center Administrator should designate either the Admissions Director or Social Worker to ensure the PASRR is completed for all potential residents. The policy also states that if a referral indicates a severe mental illness or intellectual disability, the PASRR must be completed before admission. However, the facility failed to adhere to these guidelines, resulting in incomplete and inaccurate PASRR documentation for multiple residents.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for five residents, leading to deficiencies in addressing their specific needs. Resident #104 was admitted with a diagnosis of tobacco use, but the care plan did not include any interventions related to this condition. Similarly, Resident #4 and Resident #56, both with significant mobility issues, were inaccurately assessed as requiring only partial assistance for transfers, despite staff interviews indicating the need for a mechanical lift and maximum assistance. Resident #39, who was admitted with protein-calorie malnutrition and had highly impaired vision, did not have a care plan addressing her vision loss. This oversight resulted in her being unable to identify her meals, as staff did not inform her of the contents on her tray. Additionally, Resident #6, who was readmitted with multiple diagnoses and was receiving hospice care, lacked a care plan that included hospice services, despite ongoing eligibility and discussions by the hospice interdisciplinary group. Interviews with facility staff, including a CNA, the Director of Rehabilitation, and the MDS RN, confirmed the absence of appropriate care plans for these residents. The facility's policy requires comprehensive, person-centered care plans to be developed and implemented within specific timeframes, yet these were not adhered to, resulting in unmet needs for the residents involved.
Care Plan Deficiencies for Multiple Residents
Penalty
Summary
The facility failed to ensure that care plans were revised for five residents, leading to deficiencies in their care. Resident #13, who was admitted with dementia, chronic cough, and dysphagia, had a care plan that did not reflect the current dining assistance needs as indicated by the Director of Nursing's list. The care plan inaccurately described the resident as a feeder, despite the need for cueing and assistance during meals. Resident #10, diagnosed with dementia and gastro-esophageal reflux disease, had a care plan that was not updated to reflect the need for assistance with eating, as confirmed by a hospice aide. The care plan only mentioned set-up assistance, failing to address the resident's current requirement for cueing during meals. Similarly, Resident #6, with a diagnosis of senile degeneration of the brain and delusional disorders, had a care plan that lacked documentation of a skin impairment, despite having an active treatment order for an open area on the coccyx. Resident #65, with mood disorder and delusional disorder, exhibited verbally aggressive behavior, but the care plan had not been revised with alternate interventions since the previous year. This lack of update persisted despite ongoing incidents of aggression. Lastly, Resident #89, with a history of picking at his skin, had a care plan that did not include interventions for this behavior, as confirmed by staff interviews. The facility's policy requires care plans to be updated with changes in residents' conditions, but this was not adhered to, resulting in deficiencies in care planning and implementation.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice, affecting multiple residents. Three residents were not assisted with eating as per their care plans. One resident with contracted hands was observed struggling to feed himself without the necessary adaptive equipment, such as a sippy cup, and was left unattended during meals. Another resident required cueing and assistance with eating but was left alone with her meal tray, resulting in difficulty consuming her food. A third resident, who was visually impaired, was not informed about the contents of her meals, leading to confusion and difficulty in eating. Two residents were not properly assessed for transfers and were not provided with necessary equipment like wheelchairs. One resident expressed a desire to get out of bed but was unable to do so due to the lack of a wheelchair and the discomfort caused by a mechanical lift. Another resident had her wheelchair taken for another resident's use and had been waiting for a replacement for a year, leaving her confined to bed. Both residents were not reassessed for their transfer needs during their quarterly reviews, and their care plans did not reflect their actual assistance requirements. The facility also failed to appropriately notify a change in condition for a resident who experienced an alleged abuse incident. The resident's family and primary care provider were not informed until the day after the incident, delaying necessary medical intervention. Additionally, a resident with a fracture was not adequately assessed for pain, resulting in delayed pain management. The resident reported significant discomfort and inadequate pain relief, which was only addressed after repeated complaints. Furthermore, wound care was not consistently provided for two residents, with missed dressing changes and lack of proper documentation, leading to untreated and uncovered wounds.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor food preferences for four residents, leading to dissatisfaction and unmet dietary needs. Resident #309 expressed frustration over not receiving hot tea, despite repeatedly requesting it since admission. The Food Service Director (FSD) acknowledged that a food preference sheet was not completed for this resident, which should have included hot tea as an option. The FSD admitted that any staff member could have fulfilled the resident's request, but it was not done. Resident #28, who has only three teeth, was unable to consume the chicken and asparagus provided on his lunch tray due to difficulty chewing. The resident stated that softer or ground food would be more suitable, but this need was not communicated to the staff. Staff U, an LPN assigned to the resident, was unaware of the resident's dental issues and the need for modified food textures. Resident #39, who is cognitively intact and has a diagnosis of protein-calorie malnutrition, reported not receiving her preferred breakfast items, such as yogurt and fruit, despite these preferences being documented. Additionally, Resident #71 noted the absence of condiments on meal trays, which the FSD confirmed should have been provided. The facility's policy on resident food preferences was not effectively implemented, resulting in unmet dietary needs and preferences for these residents.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to maintain the dignity of residents during meal service in the second-floor dining room. Observations revealed that residents at the same table were not served their meals simultaneously, leading to significant delays for some residents. For instance, at one table, a resident was served at 12:25 p.m., while their tablemate did not receive their meal until 12:44 p.m. Similar delays were observed at other tables, with some residents waiting up to 21 minutes after their tablemates had been served. This resulted in residents having to watch others eat while they waited for their meals, which is contrary to the facility's policy on dignity and respect. Interviews with staff, including CNAs and the Food Service Director, highlighted systemic issues contributing to the delays. Trays were delivered in room number order, and staff had to leave the dining room to deliver trays to residents' rooms, causing further delays in serving those dining in the room. The Food Service Director was unaware of the number of residents dining in the room, and the Director of Nursing stated that the expectation was for residents to be served simultaneously. The facility's policy emphasizes treating residents with dignity and respect, which was not upheld in this instance.
Failure to Honor Advance Directives for Two Residents
Penalty
Summary
The facility failed to honor the rights of two residents to formulate advance directives, leading to significant deficiencies in their care. Resident #259, who has a genetic-related intellectual disability and requires a surrogate for decision-making, was admitted to the facility with guardianship paperwork indicating that they lacked the capacity to make decisions. Despite this, the facility had the resident sign various documents, including vaccination consents and discharge paperwork, in violation of the court order. The guardian had informed the facility of the guardianship status, but the facility failed to act on this information appropriately. Resident #94, diagnosed with adult failure to thrive and schizophrenia, was also affected by the facility's failure to properly manage advance directives. The resident's admission records indicated the need for a surrogate, yet the facility incorrectly listed the resident as their own responsible party. Staff interviews revealed confusion and discrepancies in the resident's profile, with staff members acknowledging the mistake but failing to correct it. The resident's cognitive impairments were evident, yet the facility did not ensure that a surrogate was appointed to make decisions on their behalf. The facility's policies on resident rights and advance directives were not followed, leading to these deficiencies. Staff interviews highlighted a lack of communication and oversight in the admission process, with errors in documenting and verifying residents' decision-making capacities. The facility's failure to adhere to its own policies and procedures resulted in the violation of residents' rights to have their advance directives honored, as required by federal and state laws.
Failure to Protect Resident Health Information Privacy
Penalty
Summary
The facility failed to ensure the privacy of residents' personal health information on the East unit. Multiple observations were made where medication carts were left unattended with computer screens unlocked, displaying residents' medical records. These incidents occurred in areas where residents and other individuals were present, such as hallways and near the nurses' station. Additionally, a lab book with a resident's face sheet was left visible on the top counter at the nurses' station, accessible to anyone passing by. Interviews with staff, including CNAs and an LPN, revealed that they were aware of the requirement to lock computer screens and secure papers containing resident information. The Director of Nursing confirmed that staff should lock computer screens and ensure that papers with resident information are not left on top counters. The facility's policy on resident rights prohibits unauthorized access or disclosure of resident information, emphasizing the need for compliance with privacy laws.
Failure to Prevent Pressure Ulcers in Resident with Fractures
Penalty
Summary
The facility failed to prevent the development of pressure wounds for a resident who was admitted with multiple fractures and other medical conditions. The resident, who had been involved in a car accident, was observed with several new open wounds on his right leg and buttocks. These wounds developed while the resident was in the facility, and the family member noted that the wounds were related to the brace the resident wore after the accident. However, the resident no longer wore the brace while in bed, and there were inconsistencies in the use of soft boots intended to prevent pressure ulcers. Observations and interviews revealed that the resident's wound care was not consistently managed. A dressing on the resident's leg was observed to have dried drainage and was not changed daily as required. The resident was not placed on an air mattress, which was recommended for pressure ulcer prevention, and there was confusion regarding the use of a pressure-reducing cushion in the resident's wheelchair. The nursing staff, including the wound nurse, acknowledged the challenges posed by the resident's immobilizers and the need for regular skin assessments, which were not consistently performed. The facility's policy on pressure ulcer prevention and management was not adequately followed. The resident's treatment records showed multiple orders for wound care and pressure ulcer prevention, but these were not effectively implemented. The resident's wounds were documented as in-house acquired, indicating a failure in the facility's preventive measures. The Director of Nursing and the wound nurse both recognized the deficiencies in care, including the lack of an air mattress and the need for more frequent dressing changes and skin assessments.
Deficiency in Safe Environment Due to Smoking Materials and Sharp Objects
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards related to smoking materials for one resident and the presence of razors and scissors in two resident rooms. Resident #104 was observed with smoking materials in his room, which were later removed without his knowledge. The resident was unaware of the facility's smoking policy, despite having signed an agreement upon admission. The staff responsible for the smoking area was not informed of the resident's possession of smoking paraphernalia, and there was no smoking evaluation or care plan related to smoking documented in the resident's medical record. Additionally, the facility did not maintain a safe environment concerning the storage of razors and scissors. Observations revealed that a pair of scissors and razors were stored in the bathrooms of two resident rooms. Interviews with staff indicated inconsistencies in the understanding and implementation of the facility's policy regarding the storage and supervision of razors and scissors. Some staff members believed razors should be stored in a locked supply room and provided to residents only under supervision, while others stated that male residents received razors in their welcome hygiene baskets. The Director of Nursing and the Administrator acknowledged the lack of a formal policy or procedure regarding the prohibition of razors and scissors in resident rooms. The facility's approach relied on staff education and assumed knowledge, which led to the presence of these potential hazards in resident rooms. This lack of clear policy and consistent implementation contributed to the deficiency in maintaining a safe environment for residents.
Failure to Document Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure proper post-dialysis communication and documentation for a resident with end-stage renal disease who required dialysis services. The resident's medical records from late January to late February 2025 lacked documentation of post-dialysis assessments or vital signs upon return to the facility. Additionally, there were no orders addressing the resident's central line access for dialysis or documentation of post-dialysis assessments. Interviews with nursing staff revealed that while there is an option to document post-dialysis assessments in the medical record, it was not being utilized by the facility. The Director of Nursing was unaware of this documentation option and acknowledged the absence of a section for post-dialysis assessment on the current dialysis communication sheet. The facility's policy on the care of AV-fistula-grafts outlines the need to check for signs of infection and bleeding at the cannulation site after dialysis. However, the lack of documentation and communication regarding post-dialysis assessments indicates a failure to adhere to these procedures. Nursing staff stated that they assess the dialysis site and vital signs upon a resident's return from dialysis, but this information was not being recorded in the medical records. This oversight in documentation and communication could potentially impact the quality of care provided to residents requiring dialysis services.
Failure to Complete Pharmacy Recommendations for Residents
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were completed for two residents, leading to deficiencies in medication management. Resident #57 was admitted with a diagnosis of atherosclerotic heart disease and had physician orders for Peridex mouth/throat solution. The Consultant Pharmacist recommended that the order be clarified to instruct the resident to swish and not swallow the solution. However, these recommendations were not completed or signed by the physician. The Consultant Pharmacist noted that there had been ongoing issues with the facility not completing pharmacy recommendations. Resident #5, who was admitted with multiple diagnoses including brief psychotic disorder and moderate major depressive disorder, also had unaddressed pharmacy recommendations. The Consultant Pharmacist suggested specific dosing instructions for Diclofenac gel and changes to the orders for Midodrine and Calcitonin Nasal solution. These recommendations were not incorporated into the resident's physician orders. The Director of Nursing acknowledged receiving the recommendations but admitted to falling behind and missing them. Additionally, the facility lacked a policy for handling pharmacy recommendations, which contributed to the oversight.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure proper storage of medications on both units, as observed during a survey. On multiple occasions, medication carts were found unlocked and unattended, with medications left on top of the carts. Specifically, on the second floor, two bottles of medication were left on top of an unattended cart, and on the first floor, a cart was found unlocked with no staff nearby. Additionally, a nurse was observed leaving a cart unlocked after retrieving an item. Medications were also found unsecured in resident rooms, including over-the-counter medications in an open bedside drawer and medication cups left on overbed tables. Interviews with the Consultant Pharmacist and the Director of Nursing (DON) revealed that the facility's practices did not align with their policy on medication storage and labeling. The Consultant Pharmacist noted that he had also found an unlocked medication cart during his spot checks and emphasized the need for vigilance regarding medications brought in by families. The DON confirmed that all medication carts should be locked, and medications should not be left at residents' bedsides or in their rooms. The facility's policy requires medications to be stored in secured, locked locations accessible only to designated staff, which was not adhered to in these instances.
Failure to Implement Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to implement protocols from its antibiotic stewardship program for a resident who was receiving intravenous antibiotics for a severe urinary tract infection (UTI). The resident, who had been readmitted to the facility with diagnoses including infection and inflammatory reaction due to a UTI and indwelling urethral catheter, was observed with two empty bags of Vancomycin at her bedside. The resident was unaware of the duration of her antibiotic treatment, indicating a lack of communication and documentation regarding her care plan. A review of the resident's physician orders revealed that there were no end dates specified for the antibiotics Vancomycin and Cefepime, which were prescribed for the UTI. The Director of Nursing (DON) acknowledged that all antibiotics should have an end date to ensure proper monitoring of antibiotic duration, as part of the facility's antibiotic stewardship program. The facility's policy on antibiotic stewardship, revised in December 2016, requires prescribers to provide complete antibiotic orders, including the duration of treatment. The absence of an end date for the antibiotics in this case was identified as a problem by the DON.
Inaccurate Discharge Notice Issued to Resident
Penalty
Summary
The facility failed to ensure the protection of a resident's right to remain at the facility by issuing an inaccurate reason on a thirty-day Nursing Home Transfer and Discharge Notice. The notice provided to the resident cited non-payment and improved health as reasons for discharge, despite the resident not owing any money to the facility and his health not having improved sufficiently for discharge. The resident, who was cognitively intact with a BIMS score of 15, was informed of the discharge due to being combative, a reason not accurately reflected in the notice. Interviews with facility staff, including the Nursing Home Administrator, Business Office Manager, Social Worker, and Director of Nursing, revealed inconsistencies and inaccuracies in the discharge notice. The Social Worker admitted to not knowing the financial details of the resident's account and acknowledged that the physician's signature on the notice was not obtained. The Director of Nursing confirmed the resident's need for nursing care and that his health had not improved enough for discharge, contradicting the reasons stated in the notice. The comprehensive care plan indicated the resident's discharge plan was to remain in the facility, further highlighting the discrepancy in the discharge notice.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
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