Park Meadows Healthcare & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Gainesville, Florida.
- Location
- 3250 Sw 41st Place, Gainesville, Florida 32608
- CMS Provider Number
- 105193
- Inspections on file
- 25
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Park Meadows Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with orders for multiple medications, including probiotics, vitamin C, Eliquis, Famotidine, and insulin (Glargine and Apidra), had several scheduled doses in one month with no corresponding entries on the MAR. Because the resident disliked certain LPNs, nurses informally split responsibilities so that one nurse administered medications while another documented them, leading to missed documentation when the documenting LPNs forgot or were distracted. This practice conflicted with facility policy requiring the staff providing care to record medications administered, resulting in incomplete and inaccurate clinical records for the resident.
The facility was found to have an unsanitary environment across all hallways, with trash and debris present and no housekeeping staff observed during the inspection. Residents expressed dissatisfaction with the housekeeping services, and the Administrator confirmed the lack of adherence to the cleaning schedule.
A resident with a mechanical soft diet order was served a hotdog, which did not meet dietary restrictions, leading to a finding of neglect. Despite being informed by an RN, the LPN did not remove the food item, and a CNA cut the hotdog for the resident. The resident had a complex medical history, including dysphagia, increasing the risk of aspiration. Staff interviews revealed a lack of adherence to diet verification procedures, contributing to the incident.
A resident with a mechanical soft diet order was inappropriately served a hotdog, despite staff being aware of the dietary restriction. The LPN retrieved the hotdog without verifying the resident's diet, and neither the LPN nor the RN removed the food after realizing the error. The CNA cut the hotdog, but it still did not meet the mechanical soft diet requirements. This led to Immediate Jeopardy due to the facility's failure to provide a safe environment and adequate supervision.
A resident with a mechanical soft diet was improperly served a hotdog, despite staff being aware of the dietary restriction. The LPN failed to verify the diet, and the RN did not remove the food after identifying the error. The resident's complex medical history, including dysphagia, increased the risk of harm, leading to a determination of Immediate Jeopardy.
A resident with specific dietary needs was given a hotdog by an LPN without verifying the diet order, despite an RN's warning. The resident's diet required a Controlled Carbohydrates (CCHO) diet with Mechanical Soft texture. The staff failed to remove the inappropriate food item, leading to a determination of neglectful behavior and Immediate Jeopardy due to the facility's failure to implement policies and procedures for therapeutic diets.
The facility failed to serve food at an appetizing temperature, as evidenced by resident complaints and a test tray observation. Residents reported receiving cold food, and a test tray showed food temperatures below the optimal level. The facility's policy requires food to be served at a safe and appetizing temperature, which was not adhered to, resulting in the deficiency.
The facility failed to maintain a clean and secure environment in two shower rooms and the memory care unit. A resident reported mold in the shower rooms, which was confirmed by observations of black substances on the ceilings. In the memory care unit, a door had a gap due to a plywood repair, exposing the interior to the outside. The Maintenance Director was unaware of these issues, despite a policy for maintenance work orders.
The facility failed to implement a comprehensive care plan for a resident at risk for falls, as only one fall mat was placed instead of the required two. Additionally, another resident's care plan lacked focus on incontinence care, despite documented needs and staff observations. These deficiencies were contrary to the facility's policy on comprehensive assessments and care plans.
A resident did not receive blood pressure medication according to the physician's order, which specified holding the medication if the SBP was greater than 110. The medication was administered multiple times when the SBP exceeded this parameter. Interviews with the DON and Medical Director confirmed the error, but no negative impact on the resident's health was observed.
Two residents in an LTC facility did not receive dietary services as prescribed by their physicians. One resident, with Alzheimer's and other health issues, was not given the required frozen nutritional treat with meals, despite a physician's order. Another resident, with diabetes and renal disease, received insufficient meal portions, contrary to the prescribed double protein diet. Both cases highlight a failure to adhere to the facility's dietary policies, as confirmed by registered dietitians.
A facility failed to provide timely laboratory services for a resident, missing scheduled tests for Hemoglobin A1c and Depakote levels as ordered by the physician. The oversight was confirmed by the DON, who noted that the tests were conducted only after the issue was identified. The facility's policy requires timely diagnostic services, which was not followed in this instance.
A facility failed to accurately document the provision of a frozen nutritional treat for a resident with a physician's order due to weight loss. Observations showed the resident did not receive the treat during meals, despite the MAR indicating otherwise. Interviews with the DON and an LPN revealed expectations for accurate documentation and meal checks, yet discrepancies were noted.
The facility failed to ensure proper infection control practices, as observed in the actions of a CNA and an LPN who did not sanitize equipment or perform hand hygiene during medication administration. Additionally, a clean linen cart was improperly used to store personal items, violating the facility's infection control policies.
Incomplete Medication Administration Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for one resident related to medication administration. Physician orders for this resident included Acidophilus 100 mg capsules twice daily, Ascorbic Acid 500 mg tablets twice daily, Eliquis 5 mg twice daily for unspecified atrial flutter, Famotidine 20 mg twice daily for GERD, Insulin Glargine 35 units subcutaneously twice daily for diabetes in a dialysis patient, and Apidra SoloStar 8 units subcutaneously before meals for type 2 diabetes with complications. Review of the resident’s MAR for December showed missing documentation entries for multiple scheduled doses of these medications, including Acidophilus, Ascorbic Acid, Eliquis, Famotidine, Insulin Glargine, and Apidra at specified afternoon/evening administration times. Interviews with nursing staff revealed that the resident did not like certain LPNs, leading to an informal practice where one nurse would administer the medications while another nurse was responsible for documenting them on the MAR. One LPN stated she gave all of the resident’s medications on a specific date and expected another LPN to document them, while that LPN acknowledged she was supposed to document the medications but must have forgotten. Another LPN reported that, due to the resident’s verbal abuse, another nurse administered the medications while she pulled the insulin and verified with the other nurse that the medications were given, but she believed she became distracted and failed to sign off on the MAR. The facility’s policy on Charting and Documentation required that medications administered and services performed be recorded in the resident’s clinical record by the staff providing care, but this was not followed, resulting in incomplete and inaccurate medical records for the resident.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain an orderly and sanitary environment across all four hallways (100, 200, 300, and 400), as observed during a tour on March 29, 2025. Trash and debris were noted in these areas, with no housekeeping carts present during the inspection. Specific observations included significant debris near the exit to the smoking patio on the 100 hallway, consisting of leaves, grass, and small pieces of trash. Interviews with residents revealed dissatisfaction with the housekeeping services, with one resident describing it as a 'joke.' Further observations confirmed the continued presence of trash and debris, and a large, uncovered cart filled with soiled linens and trash was noted, emitting a foul odor. Additionally, a brownish dried liquid was observed on the wall in the 100 hallway. The Administrator confirmed the unsanitary conditions and acknowledged that the housekeeping staff did not work on the morning of the inspection. The Administrator stated that housekeeping personnel are expected to follow a checklist for cleaning rooms and common areas, but this schedule was not adhered to. The absence of housekeeping staff and the failure to follow the cleaning checklist contributed to the unclean environment observed during the survey.
Failure to Adhere to Dietary Restrictions Leads to Neglect
Penalty
Summary
The facility failed to protect a resident from neglect by not adhering to the prescribed dietary requirements. A resident, who had a physician's order for a mechanical soft diet, was served a hotdog and hotdog bun, which did not comply with the dietary restrictions. Despite being informed by a Registered Nurse (RN) that the resident should not have a hotdog, the Licensed Practical Nurse (LPN) did not remove the food item. The resident attempted to consume the hotdog, and a Certified Nursing Assistant (CNA) further facilitated this by cutting the hotdog in half, although this did not meet the mechanical soft diet requirements. The resident involved had a complex medical history, including chronic obstructive pulmonary disease, heart failure, muscle weakness, malnutrition, and dysphagia, which increased the risk of aspiration and choking. The Speech Therapy evaluation indicated the resident was on a mechanical soft diet due to decreased oral function and risk of aspiration. Despite these clear dietary restrictions, the staff failed to verify the resident's diet before serving the hotdog, and the error was not corrected even after it was identified. Interviews with staff revealed a lack of adherence to the facility's policies and procedures regarding diet verification and neglect prevention. The LPN admitted to freezing and not removing the plate due to the presence of a surveyor, while the RN assumed the LPN would take corrective action. The Cook and Food Service Director acknowledged that the procedure for verifying diet orders was not followed, contributing to the incident. The facility's failure to implement its policies and procedures for neglect led to the determination of Immediate Jeopardy.
Removal Plan
- Resident #45 was re-evaluated by the licensed nurse and the speech therapist.
- Resident #45's chest x-ray was completed.
- Residents were interviewed regarding abuse and neglect, and skin evaluations for residents who are not able to be interviewed were carried out to identify abuse or neglect.
- Facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out.
- The DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet.
- A root cause analysis was conducted and Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets.
- The facility Administrator, Director of Nursing, and Regional Nursing Consultant were educated by the Chief Nursing Officer Consultant on the components of abuse, neglect, exploitation, and injury of unknown origin to include reporting requirements.
- A performance improvement plan for abuse and neglect was developed and executed with the QAPI Committee and Medical Director.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery.
- 227 out of 233 facility staff members (112 out of 112 certified nursing assistants, 37 out of 38 licensed practical nurses, 14 out of 15 registered nurses, and 16 out of 16 dietary staff members) were reeducated on the accuracy of diets and abuse, neglect, exploitation, and injury of unknown origin.
- The facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process.
Inappropriate Diet Served to Resident with Mechanical Soft Diet Order
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards when a resident was served an inappropriate therapeutic diet. The incident involved a resident who had a physician's order for a mechanical soft diet due to conditions including dysphagia and risk for aspiration. Despite this, the resident was served a hotdog, which was not suitable for their dietary needs. The error was identified by a registered nurse, but neither the nurse nor the licensed practical nurse who served the meal took action to remove the inappropriate food item. The resident, who had a history of chronic obstructive pulmonary disease, heart failure, and other health issues, was observed in the dining room requesting an alternative food item. The licensed practical nurse retrieved a hotdog from the kitchen without verifying the resident's dietary restrictions. Although the registered nurse informed the licensed practical nurse that the resident should not have a hotdog, the food was not removed, and the resident attempted to consume it. A certified nursing assistant later cut the hotdog in half, but this did not meet the requirements of a mechanical soft diet. Interviews with staff revealed a lack of adherence to procedures for verifying and serving appropriate diets. The cook did not verify the resident's diet due to the absence of a meal ticket, and the licensed practical nurse did not follow the protocol of checking the diet before serving the food. The registered nurse, overwhelmed with other tasks, assumed the licensed practical nurse would correct the mistake but did not intervene directly. This series of actions and inactions led to the determination of Immediate Jeopardy, highlighting the facility's failure to provide adequate supervision and a safe environment for the resident.
Removal Plan
- Resident #45 was re-evaluated by the licensed nurse and the speech therapist.
- Resident #45's chest x-ray was completed.
- Facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out.
- The DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet.
- A root cause analysis was conducted and Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery.
- 227 out of 233 facility staff members (112 out of 112 certified nursing assistants, 37 out of 38 licensed practical nurses, 14 out of 15 registered nurses, and 16 out of 16 dietary staff members) were reeducated on the accuracy of diets.
- The facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process.
Failure to Implement Dietary Policies Leads to Immediate Jeopardy
Penalty
Summary
The facility administration failed to effectively manage resources to ensure the highest practicable physical well-being of each resident, specifically by not implementing policies and procedures related to neglect and therapeutic diets. A resident with a physician's order for a mechanical soft diet was served a hotdog, which was not in compliance with their dietary needs. Despite being informed by a registered nurse that the resident should not have a hotdog, the licensed practical nurse did not remove the food item, and a certified nursing assistant further facilitated the resident's consumption by cutting the hotdog in half. The resident in question had a complex medical history, including chronic obstructive pulmonary disease, heart failure, muscle weakness, and dysphagia, which increased their risk for aspiration and choking. The resident had been evaluated by a speech therapist and was on a mechanical soft diet due to these risks. However, the staff involved failed to verify the resident's dietary needs before serving the hotdog, and even after recognizing the error, they did not take corrective action to remove the inappropriate food item. Interviews with staff revealed a lack of adherence to established procedures for verifying and serving diets. The licensed practical nurse did not verify the resident's diet with the kitchen staff, and the cook did not follow the procedure of checking the diet ticket or verifying the diet with the nurse. The registered nurse, although aware of the dietary error, did not intervene effectively to prevent the resident from consuming the inappropriate food. This series of actions and inactions led to a determination of Immediate Jeopardy due to the potential harm posed to the resident.
Removal Plan
- Resident #45 was re-evaluated by the licensed nurse and the speech therapist.
- Resident #45's chest x-ray was completed.
- Residents were interviewed regarding abuse and neglect, and skin evaluations for residents who are not able to be interviewed were carried out to identify abuse or neglect.
- Facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out.
- The DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet.
- A root cause analysis was conducted and Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets.
- The facility Administrator, Director of Nursing, and Regional Consultant were educated by the Chief Nursing Officer Consultant on the components of abuse, neglect, exploitation, and injury of unknown origin to include reporting requirements.
- A performance improvement plan for abuse and neglect was developed and executed with the QAPI Committee and Medical Director.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery.
- 227 out of 233 facility staff members were reeducated on the accuracy of diets and abuse, neglect, exploitation, and injury of unknown origin.
- Education was completed by the Regional Nurse Consultant with the Administrator and the DON to review job descriptions and the components of QAPI.
- The facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process.
Failure to Implement Therapeutic Diet Policies
Penalty
Summary
The facility failed to utilize the Quality Assessment and Performance Improvement (QAPI) process effectively, leading to a deficiency in implementing policies and procedures for neglect and therapeutic diets. On October 15, 2024, a resident requested an alternative food item from a Licensed Practical Nurse (LPN) in the dining room. The LPN provided a hotdog and hotdog bun without verifying the resident's diet in the kitchen. A Registered Nurse (RN) identified the error, stating that the resident was not supposed to have a hotdog, but neither the RN nor the LPN removed the food item from the resident. The resident, who had a Controlled Carbohydrates (CCHO) diet with Mechanical Soft texture and thin consistency, was observed picking up the hotdog and placing it in his mouth, although he did not chew or swallow it. A Certified Nursing Assistant (CNA) then cut the hotdog in half, allowing the resident to attempt to consume it again. The resident's medical record indicated multiple diagnoses, including chronic obstructive pulmonary disease, heart failure, and diabetes, which necessitated adherence to a specific diet. The facility's failure to act upon the identified dietary error and remove the inappropriate food item was determined to be neglectful behavior. The incident was classified as Immediate Jeopardy due to the systemic breakdown in implementing the facility's policies and procedures, which was not addressed through the QAPI process. The Nursing Home Administrator acknowledged the failure to act and recognized the neglectful nature of the staff's inaction.
Removal Plan
- Resident #45 was re-evaluated by the licensed nurse and the speech therapist.
- Resident #45's chest x-ray was completed.
- Residents were interviewed regarding abuse and neglect, and skin evaluations for residents who are not able to be interviewed were carried out to identify abuse or neglect.
- Facility-wide reconciliation of the dietary system/tray tickets with physician orders were carried out.
- The DON provided training and education to the dietary staff and nursing staff on providing the diet to meet the residents' needs, nutrition and hydration assistance, and accuracy of diet.
- A root cause analysis was conducted and Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concerns related to accuracy of diets.
- The facility Administrator, Director of Nursing, and Regional Consultant were educated by the Chief Nursing Officer Consultant on the components of abuse, neglect, exploitation, and injury of unknown origin to include reporting requirements.
- A performance improvement plan for abuse and neglect was developed and executed with the QAPI Committee and Medical Director.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the Removal of Immediate Jeopardy draft plan and added daily alternate diet audit form to track alternate diet check process to ensure accuracy of diets after alternative diet is requested after meal delivery.
- 227 out of 233 facility staff members were reeducated on the accuracy of diets and abuse, neglect, exploitation, and injury of unknown origin.
- Education was completed by the Regional Nurse Consultant with the Administrator and the DON on the components of QAPI.
- The facility administration will ensure that the safety and well-being as it relates to accuracy of diets is maintained by continued participation, evaluation and intervention through clinical standup review of 24-hour report to identify change in condition, and maintaining QAPI process.
Deficiency in Serving Food at Appetizing Temperature
Penalty
Summary
The facility failed to ensure that food served to residents was at an appetizing temperature, as evidenced by multiple resident complaints and a test tray observation. Resident #105 reported that breakfast trays often arrived late, resulting in cold food. Similarly, Resident #109 also complained about receiving cold food. During a test tray observation, food temperatures were measured using a calibrated thermistor digital thermometer. The food, which included ravioli with meat sauce and Italian green beans, was placed on a tray and in an insulated cart at 12:10 PM and left the kitchen at 12:14 PM. By the time the last resident began eating at 12:42 PM, the food temperatures were recorded at 109 degrees Fahrenheit for the ravioli and 89.6 degrees Fahrenheit for the green beans, both below the optimal serving temperature. The Registered Dietitian confirmed that the optimal food temperature when served should be above 110 degrees Fahrenheit, and the kitchen ensures food is above 135 degrees when initially placed on plates. The facility's policy, last reviewed on January 31, 2024, mandates that food and drink be nutritious, palatable, attractive, and served at a safe and appetizing temperature. Despite these guidelines, the facility did not adhere to its policy, resulting in the deficiency noted during the survey.
Facility Fails to Maintain Clean and Secure Environment
Penalty
Summary
The facility failed to maintain a clean, orderly, and comfortable environment in two shower rooms and the memory care unit. During an interview, a resident reported that the shower rooms were consistently dirty and moldy. Observations confirmed the presence of a black substance in a circular pattern on the ceiling over the shower area and brown discoloration on the ceiling leading to the shower area in the 100 Hall Shower Room. Additionally, a line of black substance spots was observed on the ceiling over the area leading into the shower in the 500 Hall Shower Room. The Maintenance Director was unaware of these issues. In the memory care unit, a hallway exterior exit door had a large piece of plywood attached where glass should have been, with a 2-inch gap between the plywood and the metal door frame at the bottom, exposing the interior to the outside. During an observation with the Maintenance Director and Housekeeper Supervisors, it was confirmed that the duct tape used to secure the plywood had come off, leaving a gap. The Maintenance Director acknowledged he was unaware of the gap and the tape's failure. The facility's policy on maintenance work orders was reviewed, indicating a system for requesting and completing maintenance, but it appears this system was not effectively implemented in these instances.
Deficiencies in Care Plan Implementation and Development
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident identified as being at risk for falls. Observations on multiple occasions revealed that the resident had only one fall mat placed on the left side of the bed, despite a physician's order and care plan specifying that fall mats should be placed on both sides. This discrepancy was confirmed during interviews with a registered nurse and the Director of Nursing, who acknowledged the expectation to follow physician orders and care plans. Additionally, the facility did not develop a comprehensive care plan for another resident who was occasionally incontinent of bowel and bladder. The resident's care plan lacked a focus on incontinence care, despite the resident's condition being documented in the Minimum Data Set and physician orders for medication related to urinary retention. Interviews with staff indicated that the resident often refused to be cleaned up, yet this issue was not addressed in the care plan, contrary to the facility's policy on comprehensive assessments and care plans.
Failure to Administer Blood Pressure Medication as Prescribed
Penalty
Summary
The facility failed to administer blood pressure medication as prescribed by the physician for a resident. The physician's order for the resident, dated March 6, 2024, specified that Midodrine HCl Tablet 10 mg should be given every 8 hours for hypotension, with instructions to hold the medication if the systolic blood pressure (SBP) was greater than 110. However, the Medication Administration Record (MAR) for October 2024 showed that the medication was administered multiple times when the resident's SBP was above the specified parameter, including readings of 116, 122, 126, 124, 114, 127, 125, 123, and 112. Interviews with the Director of Nursing (DON) and the Medical Director confirmed that the medication was given outside the prescribed parameters. The DON acknowledged the error but noted that the resident had recently attended a cardiology appointment and was reportedly fine, with no negative impact observed. The Medical Director also reviewed the situation and revised the parameters, stating that the resident's health was stable and monitored, with no adverse effects from the medication administration error.
Failure to Provide Prescribed Dietary Services
Penalty
Summary
The facility failed to provide dietary services as prescribed by the physician for two residents, leading to deficiencies in their nutritional care. Resident #43, who has a history of Alzheimer's dementia, feeding difficulties, and other health issues, was observed multiple times without receiving the prescribed frozen nutritional treat with meals, despite a physician's order for it due to weight loss. The resident's care plan indicated a risk for alteration in nutrition and hydration, yet the prescribed dietary interventions were not consistently followed, as evidenced by the absence of the nutritional treat during meal observations. Resident #128, who has a diagnosis of type 2 diabetes mellitus, end-stage renal disease, and other health conditions, was also not provided with meals that met the prescribed dietary requirements. The resident's physician order specified a renal controlled carbohydrate diet with double meat/protein with meals, but observations revealed insufficient meal portions, such as a half peanut butter and jelly sandwich for lunch, which was deemed inadequate by the registered dietitian. The resident experienced significant weight loss, further indicating that the dietary needs were not being met as prescribed. The facility's policy and procedure for providing diets to meet the needs of each resident were not adhered to, as both residents did not receive meals consistent with their physician's orders. The registered dietitians acknowledged the inadequacy of the meals provided, highlighting a failure in the facility's food and nutrition services to ensure that residents' nutritional and hydration needs were met according to their individual care plans and physician orders.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide necessary laboratory services for a resident, specifically for the monitoring of Hemoglobin A1c and Depakote levels, as ordered by the physician. The physician's order, dated June 18, 2024, required these tests to be conducted every three months. However, a review of the resident's medical record revealed no documentation of the laboratory tests being performed in September 2024. During an interview, the Director of Nursing confirmed that the lab work was not completed as scheduled and stated that the blood was drawn on the morning of October 17, 2024, after the oversight was discovered. The facility's policy, last reviewed on January 31, 2024, mandates the provision of timely laboratory, radiology, and diagnostic services when ordered by a physician or other qualified healthcare professionals. This policy was not adhered to in the case of the resident, leading to a deficiency in meeting the resident's healthcare needs.
Failure to Accurately Document Nutritional Supplementation
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for a resident identified as having a physician's order for a frozen nutritional treat with meals due to weight loss. Observations over several days revealed that the resident did not receive the frozen nutritional treat during meals, despite the physician's order. Specifically, during meal observations on multiple occasions, the resident was noted to be eating various meals without the prescribed frozen nutritional treat. The Medication Administration Record (MAR) inaccurately documented that the resident received the frozen nutritional treat at specified times, which was contradicted by direct observations. Interviews with the Director of Nursing and a Licensed Practical Nurse highlighted expectations for accurate documentation and meal tray checks, yet discrepancies persisted. The facility's policy on charting and documentation mandates that services provided to residents be accurately recorded, which was not adhered to in this case.
Infection Control Deficiencies in Hand Hygiene and Linen Handling
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during medication administration and the handling of medical equipment and clean linens. During observations, a Certified Nursing Assistant (CNA) did not sanitize a vital sign machine between residents, using it on multiple residents without cleaning. The CNA acknowledged the oversight, stating that disinfecting wipes were not available on their cart at the time. Additionally, a Licensed Practical Nurse (LPN) was observed not performing hand hygiene before and after administering medications to residents, even after donning and doffing gloves. The LPN admitted to not using hand sanitizer between residents, which is against the facility's hand hygiene policy. Furthermore, the facility did not maintain a clean storage environment for linens. A clean laundry cart was found with a bottle of coke and a bag of chips among the clean sheets, which was confirmed by the Housekeeping Supervisor as inappropriate. The facility's policy on handling linens to prevent infection was not adhered to, as evidenced by the improper storage of personal items on the clean linen cart.
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.
