Pine Trail Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Worth, Florida.
- Location
- 4445 Pine Forest Dr, Lake Worth, Florida 33463
- CMS Provider Number
- 105835
- Inspections on file
- 21
- Latest survey
- April 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Pine Trail Nursing And Rehab Center during CMS and state inspections, most recent first.
The facility failed to refund the personal funds of three residents within the required 30-day period following their discharge or expiration. Despite the facility's policy to refund overpayments within 30 days, refunds for a resident who expired and two residents who were discharged were delayed by over three months. The Business Office Manager attributed the delays to the corporate office's processing and acknowledged a lack of access to timely reports on check issuance.
The facility failed to issue refunds to three residents or their representatives within the required 30-day period following discharge. Refunds were delayed by over three months due to a lack of timely processing by the corporate office. The Business Office Manager was unaware of the delays until the survey and did not have access to the necessary reports to track refund issuance.
A resident with severe cognitive impairment and a history of falls was found on the floor with a hip fracture, but the facility failed to update the care plan or conduct a thorough investigation. The fracture was deemed pathological without supporting documentation, and required safety measures like floor mats were absent. The event was not reported as a deficiency by the facility.
The facility failed to maintain adequate hot water temperatures, secure handrails, and accessible emergency call systems, impacting resident comfort and safety. Observations revealed cold water temperatures in several rooms, worn handrails, and short emergency cords. Additionally, fluorescent light fixtures lacked covers, and personal property and medical records were unsecured. Fire doors were also improperly propped open, indicating a lack of maintenance and oversight.
The facility failed to follow regular diet menus, affecting 53 residents. Due to a non-working oven, the facility used a 7 Day Hot Weather/Cold Food Menu but did not adhere to it consistently. Improvisations were made due to equipment failures, and the facility lacked a scale to measure food portions accurately, leading to estimations. The Certified Dietary Manager communicated the need for a scale to the owner, but no action was taken.
The facility failed to maintain sanitary conditions in food storage and preparation, affecting 53 of 55 residents. Observations revealed open and improperly stored food, unlabeled substances, rusty surfaces, and missing panels on the ice machine. The walk-in refrigerator and freezer contained open items without dates, and the dry goods pantry had numerous open items. A dietary aide was observed without a beard net, and the CDM admitted to inadequate sanitization practices.
The facility's administration failed to manage resources effectively, affecting all residents. Four LPNs administered IV medications without certification, and a resident's unwitnessed fall with a fracture was not properly reported or investigated. The Administrator was unaware of a pest control issue, and two broken ovens were observed in the kitchen.
The facility's QAPI/QAA failed to implement effective corrective actions for repeated deficiencies in food services and pest control, affecting all 55 residents. Deficiencies included issues with menus, kitchen sanitation, and pest control, previously cited during a survey. The Administrator acknowledged these ongoing issues during a recent interview.
The facility failed to maintain kitchen equipment, with two broken ovens and issues with the walk-in freezer and refrigerator not maintaining temperatures. The kitchen also lacked a scale for weighing food, an issue noted by the CDM since May 2024. The Administrator was unaware of these deficiencies until the survey.
The facility failed to maintain an effective pest control program, resulting in a roach infestation observed in resident rooms and common areas. Multiple residents reported seeing roaches, and the Nursing Home Administrator was unaware of the issue until informed by surveyors. The facility's pest control services were inconsistent, with a gap in service while searching for a cheaper provider, and the new service was ineffective, as residents continued to report sightings.
The facility failed to ensure dignity during dining for two residents. A CNA was observed standing while feeding a resident with severe cognitive impairment, contrary to usual practice. Another resident, with Alzheimer's and hand stiffness, experienced a delay in receiving feeding assistance, as trays for those needing help were delivered last. An LPN referred to this resident as a "feeder," contributing to the delay.
Two residents experienced inadequate care due to staffing shortages. One resident, with Major Depressive Disorder, was unable to walk outside independently due to lack of staff availability, while another resident requiring substantial assistance faced delays in transfers and meal assistance. Staff confirmed the facility's short-staffing, leading to rushed care and unmet resident needs.
A resident with severe cognitive impairment experienced a fall resulting in a confirmed acute left acetabular fracture. Despite this, the facility's IDT concluded the fracture was spontaneous and not due to the fall, based on undocumented hospital records. The facility did not report the incident, as the Administrator believed it was not reportable. Interviews revealed a lack of documentation and consultation with the physician regarding the decision.
A facility failed to complete a Quarterly MDS assessment within the required time frame for a resident. The resident's assessment was due but not started or completed on time due to the MDS coordinator being overwhelmed and out sick, with no coverage available. The coordinator mistakenly believed she had more time to complete the assessment and could not provide documentation to support this claim.
A resident with a PICC line received IV Vancomycin from multiple LPNs who lacked the required IV certification. The facility failed to ensure that these LPNs met the necessary competency and knowledge requirements for administering IV therapy, as mandated by the Florida Board of Nursing. The Director of Nurses was unaware of the lack of certification among the LPNs involved.
A facility failed to maintain a sanitary PICC line dressing for a resident. The dressing was not changed since admission, despite a physician's order for weekly changes. An LPN inaccurately documented the dressing changes, and the DON confirmed the lack of a policy for PICC line dressing changes.
A resident with a primary diagnosis of an unspecified neck fracture and a BIMS score indicating cognitive intactness did not receive the required pre and post-respiratory assessments during nebulizer treatment. A registered nurse administered the treatment without evaluating the resident's baseline respiratory rate, pulse, oxygen saturation, and breath sounds, as required by the facility's nebulizer competencies. The Nursing Home Administrator acknowledged the absence of a specific policy for respiratory care, relying instead on nebulizer competencies.
The facility failed to adequately monitor side effects and behaviors for residents on psychotropic medications, as evidenced by incomplete and inaccurate documentation in MARs and TARs. Interviews with staff revealed inconsistencies in documentation practices, with several residents' records lacking required monitoring details. This deficiency affected residents with conditions such as depression, anxiety, and mood disorders, highlighting a systemic issue in medication management.
A resident with a history of cerebral infarction and hypertension was administered the incorrect dosage of Nifedipine due to a failure in updating medication orders and removing discontinued medications. The resident received a 60 mg dose instead of the prescribed 90 mg, despite having a systolic blood pressure below the safe administration threshold. The error was attributed to a pharmacy communication issue and oversight by nursing staff.
The facility failed to implement an effective infection control program, as evidenced by a resident with a PICC line not being placed on Enhanced Barrier Precautions (EBP), staff not donning PPE gowns during catheter care, and unsanitary meal tray transportation. These deficiencies highlight gaps in staff training and awareness, as well as a lack of action to address known issues.
Delayed Refunds of Resident Funds
Penalty
Summary
The facility failed to refund the personal funds of three residents within the required 30-day period following their discharge or expiration. The admission packet of the facility clearly stated that any overpayment would be refunded within 30 days. However, for Resident #1, who expired, a refund of over $1040 was delayed, with the family receiving the check approximately 3 months and 8 days after the resident's expiration. Similarly, Resident #2 was discharged, and a refund of $23,857.87 was processed approximately 3 months and 19 days later. Resident #3, who also expired, had a refund of $664.63 processed after the same delay of 3 months and 19 days. The Business Office Manager (BOM) explained that the facility's process involves sending a package for each resident to the corporate office, which then processes the refunds. The BOM believed that the packages were sent on time but acknowledged that the checks were delayed. She noted that she did not have access to the report showing the dates the checks were issued, which contributed to the delay. The BOM agreed with the findings of the surveyor, indicating a lapse in the facility's refund process management.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident # 1 refund issued Resident #2 refund issued Resident # 3 refund issued 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review of discharged residents since to current to ensure refunds are issued within 30 days of discharge by the Business Office Manager/ designee to be completed by 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Business Office Manager re-educated by the Administrator on the components of this regulation and to ensure refunds are issued within 30 days of discharge completed 4) 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: Ongoing quality monitoring to be completed by the Business Officer Manager /designee to ensure refunds are issued within 30 days of discharge 2 x weekly x 4 weeks then weekly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Delayed Refunds to Residents Post-Discharge
Penalty
Summary
The facility failed to refund the residents or their representatives all refunds due within 30 days from the residents' date of discharge, as required by regulations. This deficiency was identified for three residents. Resident #1 expired and had a refund amount of over $1040 owed, which was only received by the family approximately 3 months and 8 days after the resident's death. Similarly, Resident #2 was discharged and received a refund of $23,857.87 approximately 3 months and 19 days later. Resident #3 also expired, and a refund of $664.63 was processed approximately 3 months and 19 days after discharge. The Business Office Manager (BOM) explained that the facility's process involves sending a package for each resident to the corporate office, which then processes the refunds. However, the BOM believed she had sent the refund requests on time and was unaware of the delay until the survey. She did not have access to the report showing the dates the checks were issued, which contributed to the delay in processing the refunds. The BOM agreed with the findings after reviewing the refund dates with the surveyor.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident #1 refund issued Resident #2 refund issued Resident #3 refund issued 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review of discharged residents since to current to ensure refunds are issued within 30 days of discharge by the Business Office Manager/designee to be completed by. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Business Office Manager re-educated by the Administrator on the components of this regulation and to ensure refunds are issued within 30 days of discharge completed. 4) 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: Ongoing quality monitoring to be completed by the Business Office Manager/designee to ensure refunds are issued within 30 days of discharge 2 x weekly x 4 weeks then weekly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Failure to Ensure Adequate Supervision and Safety Measures
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices to prevent accidents and injuries for a resident with severe cognitive impairment. The resident, who had a history of falls and was at risk for injury, was found on the floor next to his bed with signs of pain in the left hip. An x-ray revealed an acute left acetabular fracture, and the resident was sent to the emergency room for evaluation. However, the facility's fall investigation did not include the fracture or any follow-up actions, and there were no updates to the care plan post-fall. Interviews with the Director of Nurses (DON) and the Rehab Director revealed that the facility concluded the fracture was a spontaneous pathological event based on hospital records, although no documentation was provided to support this claim. The DON admitted that no in-services were conducted with the staff, and there was no documentation of the interdisciplinary team meeting where this conclusion was reached. The care plan for the resident included various interventions, but there were no new interventions added after the fall with the fracture. Observations of the resident's room showed that floor mats, which were part of the care plan, were not present. A Certified Nursing Assistant (CNA) confirmed that she had never seen floor mats by the resident's bed. The Administrator stated that the event would not be reported as it was determined to be a pathological fracture, and no immediate or 5-day report was made. This lack of documentation and follow-up indicates a deficiency in ensuring a safe environment and adequate supervision for the resident.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to ensure adequate hot water temperatures in several residents' rooms and a shower room, impacting the comfort and hygiene of the residents. Observations revealed that the hot water temperatures in rooms 4, 27, and 28, as well as a shower room, were significantly below the required levels, with temperatures ranging from 84°F to 95°F. Residents reported that the water was often too cold for showers, and staff interviews confirmed that the issue had persisted for weeks. Despite maintenance logs indicating awareness of the problem, the issue remained unresolved, with the Maintenance Supervisor initially unaware of the extent of the problem. Additionally, the facility failed to maintain a safe and homelike environment in other areas. Handrails in four hallways were found to be worn and loosely affixed to the walls, posing a potential safety hazard. Emergency call system cords in five resident bathrooms were too short and inaccessible, and fluorescent light fixtures above 60 of 61 beds lacked proper covers. Furthermore, the facility did not secure residents' personal property and medical records, with boxes of medical records and personal items stored haphazardly in a conference room and the Central Supply Room. The facility also had issues with fire safety, as observed with fire doors being propped open in two hallways. The Regional Director of Maintenance acknowledged that this was against protocol. The combination of these deficiencies indicates a lack of adequate maintenance and oversight, affecting the safety and comfort of the residents. Interviews with staff revealed a lack of awareness and urgency in addressing these issues, contributing to the ongoing deficiencies.
Failure to Follow Regular Diet Menus and Portion Control
Penalty
Summary
The facility failed to adhere to the regular diet menus, impacting 53 out of 55 residents on a regular diet. The Pine Trail Menu for the week listed specific meals for each day, but the facility did not follow these menus. On Monday, the facility served sliced turkey on bread with cooked carrots and pineapple tidbits instead of the scheduled open-face hot turkey sandwich with garlic mashed potatoes and California blend vegetables. On Wednesday, the facility served pasta with meat and tomato sauce containing sausage, along with cooked sliced carrots and peas with sliced peaches, instead of the scheduled beef cubed steak with onion gravy and scalloped potatoes. The Certified Dietary Manager explained that the facility had been using a 7 Day Hot Weather/Cold Food Menu due to a non-working oven and had been substituting items to provide at least one hot component per meal. Further issues were identified when the facility did not follow the 7 Day Hot Weather/Cold Food Menu on Wednesday, as they had to discard refrigerated and frozen food due to malfunctioning equipment. The Certified Dietary Manager improvised with a pasta dish, using sausage that was also served for breakfast to prevent spoilage. Additionally, the facility lacked a scale to measure food portions accurately, leading to estimations of serving sizes. The Certified Dietary Manager acknowledged the absence of a scale since her arrival in May 2024 and had communicated this need to the owner, but no action had been taken to address the issue.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to ensure food was stored and served in a sanitary manner, potentially affecting 53 of 55 residents. During an initial kitchen tour, several deficiencies were observed, including open cheese in a refrigerator, wet baking potatoes in a cardboard box, and divided plates stored improperly. Additionally, there were unlabeled substances, rusty surfaces, and missing panels on the ice machine, which exposed corroded material. The walk-in refrigerator contained several open items with no dates, and the walk-in freezer had items exposed to air with no dates, some of which were partially defrosted or had freezer burn. The dry goods pantry also had numerous open items without dates, and the kitchen had cracked and missing plastic covers on light fixtures, stained cutting boards, and dirty baking sheets and pots. During an observation, a dietary aide was seen working without a beard net, and the Certified Dietary Manager (CDM) admitted to several issues, including the lack of sanitization chemicals in red buckets and the absence of proper sanitization of food prep surfaces. The CDM also mentioned that the administration was aware of broken ovens and the ice machine's condition. These observations and interviews highlight significant lapses in maintaining sanitary conditions in the facility's food storage and preparation areas.
Deficiencies in Administration and Resource Management
Penalty
Summary
The Administrator failed to ensure the facility was administered effectively and efficiently, impacting all 55 residents. Four LPNs were found administering IV medications without proper IV certification, which is a violation of standard care protocols. Additionally, a resident experienced an unwitnessed fall resulting in a fracture, and there was no immediate or 5-day report completed. The fall investigation did not determine the cause or assess the interventions in place at the time. Furthermore, the Administrator was unaware of a pest control issue, with no interior pest treatment conducted since the last exterior treatment. During a kitchen tour, two ovens were found broken, indicating a lack of maintenance and resource management.
Repeated Deficiencies in Food Services and Pest Control
Penalty
Summary
The facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to implement effective corrective actions for identified quality deficiencies, as evidenced by repeated deficient practices. These deficiencies were related to F803, concerning menus meeting resident needs and being prepared in advance and followed; F812, regarding food procurement, storage, preparation, and serving in a sanitary manner; and F925, involving the maintenance of an effective pest control program. These issues were identified during the Recertification and Relicensure survey, with an exit date of 09/28/23, and have the potential to affect all 55 residents residing in the facility at the time of the survey. The facility's survey history review revealed that these deficiencies were previously cited, indicating a lack of effective corrective action plans. During an interview with the facility's Administrator, it was acknowledged that these deficiencies would be cited again in the current survey, highlighting the ongoing nature of the issues.
Failure to Maintain Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating conditions, as observed during a kitchen tour. Two ovens were found broken and labeled as such. Additionally, the Certified Dietary Manager (CDM) indicated potential issues with the walk-in freezer and refrigerator, which were later confirmed by the Administrator. The Administrator discovered that the freezer and refrigerator were not maintaining appropriate temperatures and had contacted a vendor for repairs, but only the freezer was addressed. Further interviews revealed that the kitchen lacked a scale for weighing food, a deficiency noted by the CDM since May 2024. The CDM communicated this issue to her superior, but no action was taken. The Administrator was unaware of the scale's absence and the refrigerator and freezer issues until the survey. Although she received emails about the broken ovens, there was no documentation or invoices regarding their repair or replacement.
Ineffective Pest Control Program Leads to Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of roaches in various stages of life in one of the hallways and multiple resident rooms. Observations on different dates revealed live and dead roaches, as well as roach eggs, in Resident #7's room and other areas. Residents, including Resident #22, Resident #49, and Resident #44, confirmed seeing roaches in their rooms, with Resident #44 expressing concern that his family was reluctant to visit due to the infestation. The Nursing Home Administrator (NHA) was unaware of the issue until informed by surveyors and was unable to provide evidence of consistent pest control services. The facility's pest control services were inconsistent, with a gap in service during October 2024 while searching for a more affordable provider. The previous exterminator targeted rodents, flies, and fire ants, but the new company, [Company Name] Solutions, documented no obvious signs of insect activity during their initial inspection. However, residents continued to report roach sightings, indicating the new service was ineffective. The NHA acknowledged the ineffectiveness of the cheaper pest control company and noted that the scheduled service for the week of 12/16/24 was missed due to an emergency, further contributing to the ongoing pest issue.
Failure to Ensure Dignity During Dining
Penalty
Summary
The facility failed to ensure dignity during dining for two residents. For the first resident, who was admitted with Alzheimer's Disease, Dementia, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, and Nonexudative Age-Related Macular Degeneration, a Certified Nursing Assistant (CNA) was observed standing over the resident while feeding her oatmeal. The resident, who had a severe cognitive impairment as indicated by a Brief Interview of Mental Status (BIMS) score of 3, usually fed herself. However, on this occasion, the CNA noticed the resident had not eaten and decided to feed her while standing, which is not the usual practice. For the second resident, who was admitted with Alzheimer's Disease and stiffness in both hands, the facility failed to provide timely assistance with feeding. The resident's lunch tray was delivered 19 minutes after her roommate received theirs, and she was assisted with feeding 14 minutes after her tray was delivered. The resident's BIMS score could not be completed due to communication difficulties, and she was on a regular diet with pureed texture fortified foods. A Licensed Practical Nurse (LPN) referred to the resident as a "feeder" and explained that trays for residents who need assistance are passed last, which resulted in the delay.
Staffing Shortages Impact Resident Care and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of its residents due to insufficient staffing, impacting the well-being of two residents. Resident #48, diagnosed with Major Depressive Disorder, expressed a desire to walk outside the facility independently, as he used to do. However, he was informed that he could only do so if accompanied by staff, which was rarely possible due to staffing shortages. The Director of Nursing confirmed that residents could not leave the facility without staff accompaniment, even if they had an intact cognitive response, citing safety concerns. This restriction led Resident #48 to feel confined and unable to enjoy outdoor activities as he preferred. Resident #52, who requires substantial assistance for activities of daily living due to conditions such as muscle weakness and abnormal posture, experienced delays in receiving necessary assistance. Observations revealed that a CNA struggled to find another staff member to help with a Hoyer lift transfer, eventually receiving assistance from the Director of Admissions, who lacked proper training. Additionally, Resident #52 reported difficulties in receiving help with meals, often having to eat in his room due to delays in being transferred to the dining area. Staff interviews confirmed that the facility was short-staffed, leading to rushed care and inadequate support for residents' needs. The facility's staffing issues resulted in residents not receiving the care and services required to maintain their highest practicable well-being. The lack of available staff to assist with outdoor activities and necessary transfers, as well as the improper use of untrained personnel for resident care, highlighted the facility's failure to meet regulatory requirements for accommodating residents' needs and preferences.
Failure to Report Fall with Fracture
Penalty
Summary
The facility failed to report an adverse event involving a resident who experienced a fall resulting in a fracture. The resident, who had severe cognitive impairment and a history of an unspecified intracapsular fracture of the left femur, was found on the floor next to his bed, showing signs of pain in the left hip. An x-ray confirmed an acute left acetabular fracture, and the resident was sent to the emergency room for evaluation. Despite these findings, the facility's Interdisciplinary Team (IDT) concluded that the fracture was spontaneous and not a result of the fall, based on hospital records, although no documentation or consultation with the physician supported this conclusion. Interviews with the Director of Nurses (DON), Rehab Director, and Administrator revealed that the facility did not report the incident as they believed it was a pathological fracture. The DON admitted there was no documentation of the IDT meeting where this decision was made, and the Rehab Director could not find any hospital notes confirming a pathological fracture. The Administrator stated that she reviewed the regulations and determined the event was not reportable, thus no immediate or day-5 report was submitted. There was no documented evidence to support the facility's conclusion that the fracture was pathological.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a Quarterly Minimum Data Set (MDS) assessment within the regulated time frame for one resident. Resident #46 was admitted to the facility, and an admission assessment was conducted with an assessment reference date (ARD) of May 5, 2024. A subsequent quarterly assessment was completed with an ARD of August 5, 2024. The next quarterly assessment was due on November 5, 2024, but was not started by that date and remained incomplete as of December 17, 2024. During an interview, the MDS coordinator, who is the sole coordinator for the facility, stated she was overwhelmed with work and had been out sick, with no one available to cover her duties. She mistakenly believed she had an additional 30 days to complete the assessment, but could not provide documentation to support this claim. The coordinator has been working in the facility since mid-2024 and has been performing MDS assessments since 2013.
LPNs Administer IV Medication Without Certification
Penalty
Summary
The facility failed to ensure that the administration of intravenous (IV) medication met professional standards of quality for four Licensed Practical Nurses (LPNs) employed by the facility. This deficiency was identified in the case of a resident with a Peripherally Inserted Central Catheter (PICC) line, who was receiving Vancomycin intravenously for aspiration pneumonia. The Florida Board of Nursing requires LPNs to complete a minimum of a 30-hour post-graduation course in IV therapy, including specific training for central and PICC lines, to be certified to administer IV therapy. However, the personnel files for the LPNs involved did not contain the necessary IV certification. The resident in question was admitted to the facility with a PICC line in place and had a medical history that included a fracture of the neck, pneumonitis, and dysphagia. The Medication Administration Record (MAR) for the resident showed that Vancomycin was administered intravenously by different LPNs over several days. Despite the administration of IV medication, there was no documentation of IV certification for the LPNs involved, which is a requirement for administering such therapy. The Director of Nurses (DON) was interviewed and stated that she was unaware that the LPNs administering IV medications to the resident were not IV certified. This lack of awareness and oversight contributed to the deficiency, as the facility did not ensure that the LPNs met the competency and knowledge requirements necessary to administer IV therapy safely and in compliance with professional standards.
Failure to Maintain Sanitary PICC Line Dressing
Penalty
Summary
The facility failed to maintain a Peripherally Inserted Central Catheter (PICC) line in a sanitary manner for a resident. The resident was admitted with a PICC line and had a physician's order for the dressing to be changed every Tuesday night shift. However, the dressing was observed to be dated 11/27/24, indicating it had not been changed since the resident's admission. Despite this, the Treatment Administration Record (TAR) was initialed by an LPN as if the dressing had been changed on three separate occasions. The Director of Nurses acknowledged the discrepancy and confirmed there was no policy for PICC line dressing changes, stating they follow doctor's orders.
Failure to Conduct Pre and Post-Respiratory Assessments
Penalty
Summary
The facility failed to provide a proper assessment before and after administering respiratory care to a resident. Resident #365, who was cognitively intact with a BIMS score of 15, was admitted with a primary diagnosis of an unspecified fracture of the neck. The resident had an active order for Ipratropium-Albuterol inhalation solution to be administered every six hours as needed for shortness of breath and/or wheezing. The order required a pre and post-administration assessment of lung sounds, including documentation of specific lung sound characteristics. During a medication administration observation, a registered nurse, Staff Q, administered the nebulizer treatment to the resident without conducting the required pre or post-respiratory assessment. Staff Q admitted to forgetting to perform the assessments, which he normally does. The Nursing Home Administrator confirmed that there was no specific policy for respiratory care and nebulizer administration, and the facility relied on nebulizer competencies for guidance. A review of Staff Q's competency assessment indicated that he was expected to evaluate the resident's baseline respiratory rate, pulse, oxygen saturation, and breath sounds before and after treatment, which was not done in this instance.
Inadequate Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure adequate monitoring of side effects and behaviors for residents receiving psychotropic medications. This deficiency was identified for five residents, each of whom was prescribed various psychotropic medications for conditions such as depression, anxiety, and mood disorders. The facility's records, including Medication Administration Records (MAR) and Treatment Administration Records (TAR), showed inconsistencies and inaccuracies in documenting the monitoring of side effects and behaviors as required by physician orders. For instance, Resident #6's MAR from December 9 to December 16 documented monitoring with check marks instead of the required 'Y' or 'N', and there was no documentation of behaviors or side effects in the progress notes. Interviews with facility staff, including registered nurses and the Director of Nursing (DON), revealed a lack of proper documentation practices. Staff members acknowledged that monitoring for side effects and behaviors should be documented on the MAR and in progress notes, but admitted that this was not consistently done. For example, Staff K and Staff O confirmed that interventions and side effects should be documented, yet the records for Resident #6 and others did not reflect this practice. The DON also acknowledged the documentation deficiencies, noting that not all nurses documented side effects or behaviors in the progress notes as required. The deficiency was further highlighted by the absence of behavior monitoring documentation for other residents, such as Resident #32, Resident #11, Resident #48, and Resident #5. These residents were prescribed medications for various psychiatric conditions, and their records similarly lacked the required documentation of monitoring for side effects and behaviors. The facility's failure to adhere to physician orders and document monitoring accurately indicates a systemic issue in ensuring the safety and well-being of residents receiving psychotropic medications.
Medication Administration Error Due to Incorrect Dosage
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as observed during a medication administration for a resident with a history of cerebral infarction, diabetes mellitus, hypertension, and cardiomegaly. The resident was administered Nifedipine ER 24-hour 60 mg instead of the prescribed 90 mg, despite having an order to hold the medication if the systolic blood pressure (SBP) was less than 110. At the time of administration, the resident's SBP was 101, which was outside the parameters for safe administration. The error was identified during a medication pass observation, where it was noted that the medication punch card still contained the discontinued 60 mg dose, and the new 90 mg dose had not been received due to a pharmacy error. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged the oversight, noting that the discontinued medication was not removed from the medication cart, and the new order was not properly received or documented. The Consultant Pharmacist confirmed that the order for the 90 mg dose was sent to the wrong pharmacy, resulting in the facility not receiving the correct medication. The resident was monitored for side effects, and the physician was contacted to revert the order back to 60 mg due to the resident's current blood pressure. The incident highlighted a breakdown in communication and medication management processes within the facility.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection control program, as evidenced by several deficiencies observed during the survey. One resident, who was admitted with a Peripherally Inserted Central Catheter (PICC) line, was not placed on Enhanced Barrier Precautions (EBP) as required. There was no physician's order for EBP, no signage indicating EBP, and no personal protective equipment (PPE) available near the resident's room. This oversight was acknowledged by the Director of Nursing, who realized the necessity of these precautions for the resident. Another deficiency was observed during the provision of perineal and catheter care for a resident with an indwelling catheter. The staff involved in the care did not don PPE gowns, which are required under EBP guidelines. Despite following hand hygiene protocols and using clean gloves, the absence of gowns indicated a lack of understanding and training regarding EBP among the staff. Interviews with the Certified Nursing Assistants involved revealed confusion about EBP, highlighting a gap in staff education and awareness. Additionally, the facility failed to ensure meal trays were transported in a sanitary manner. Observations revealed that meal carts used to transport trays were missing doors, compromising their cleanliness. Interviews with dietary staff and the Certified Dietary Manager confirmed that the carts had been in this condition for an extended period, with the administration being aware of the issue. This lack of action to address the unsanitary condition of the meal carts further demonstrated deficiencies in the facility's infection control practices.
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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