Pinellas Park Fl Opco, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Pinellas Park, Florida.
- Location
- 8701 49th St N, Pinellas Park, Florida 33782
- CMS Provider Number
- 105422
- Inspections on file
- 25
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 4 (3 serious)
Citation history
Health deficiencies cited at Pinellas Park Fl Opco, Llc during CMS and state inspections, most recent first.
A resident with intact cognition and multiple chronic conditions had clearly documented Full Code status confirmed through advance care planning, physician notes, nursing assessments, and the care plan. In the early morning, CNAs found the resident unresponsive, without a pulse, and not breathing, and notified an LPN, who delayed while checking an oximeter, verifying code status, and sending CNAs to get additional nurses instead of calling a code blue or starting CPR. The LPN later stated she believed the resident was already dead and did not initiate compressions, and the responding RN and another LPN, summoned to "pronounce" the resident, assumed a DNR status, did not verify code status, and also did not begin CPR. No staff performed CPR before EMS arrival; EMS confirmed the resident was Full Code, questioned the lack of CPR, and then initiated resuscitation efforts, which were unsuccessful, leading surveyors to cite the facility for failing to protect the resident from neglect by not honoring the resident’s advance directive for resuscitation.
A resident with intact cognition and multiple chronic conditions had clearly documented Advance Care Planning and physician orders confirming Full Code status. In the early morning, CNAs found the resident unresponsive, without a pulse or respirations, and notified an LPN, who delayed responding, used a pulse oximeter showing low oxygen saturation, and left the room to check code status instead of calling a code blue or starting CPR. CNAs were sent to obtain additional nurses from another floor, leaving the resident alone, and when multiple nurses arrived, they did not verify the code status promptly, assumed the resident was a DNR based on how the situation was presented, did not call a code blue, and did not initiate CPR. The assigned LPN acknowledged not performing compressions, stating she believed the resident was already dead and needed a backboard and help to move him, and other nurses confirmed that no CPR was performed before EMS arrival. EMS questioned why CPR had not been started for a Full Code resident and then initiated resuscitation, and surveyors determined that CPR was not initiated for approximately 35 minutes, resulting in physical pain and death and leading to an Immediate Jeopardy citation.
A resident with a documented full code status was found unresponsive and without vital signs, but multiple staff, including CNAs, an LPN, and RNs, failed to initiate CPR or call a code blue. The assigned CNA and another CNA reported that the LPN delayed responding, obtained an oxygen saturation of 60, left to verify code status, confirmed the resident was full code, yet did not start compressions or call a code, and no staff performed CPR before EMS arrived. The LPN later stated she believed the resident was already dead, did not call a code, did not ask CNAs for help to move the resident or use a backboard, and acknowledged that no interventions were performed while they waited for EMS. Other nurses who came to the room assumed the resident was a DNR based on how the situation was presented, did not independently verify code status, did not initiate CPR, and did not call a code blue. EMS questioned why CPR had not been started for a full code resident, and the medical director confirmed that facility expectations and protocol required immediate CPR for an unresponsive full code resident and did not authorize nurses to pronounce death.
Surveyors found that a resident with dementia, severe cognitive impairment, incontinence, and dependence for toileting hygiene had multiple missing entries in ADL documentation over a short stay, with no recorded incontinence care for most toileting opportunities and no record of meals provided for most mealtimes. Staff later could not recall the resident or the care given, and the DON confirmed that documentation should reflect whether care or meals were provided or refused and that blanks were not acceptable. The resident’s MDS and care plan showed total dependence, always-incontinent status, and skin integrity risk, while facility policies required appropriate incontinence care, ADL support, and meal service, but there was no facility policy provided on documentation.
The facility's kitchen was found to be unsanitary and poorly maintained, with a broken handwashing sink, blocked dishwashing area, and inadequate lighting. Observations revealed rusted equipment, debris, and dirt buildup, while staff interviews indicated a lack of adherence to cleaning protocols. Despite documentation of completed cleaning tasks, the facility failed to maintain a clean and sanitary kitchen environment.
The facility failed to label medications according to professional standards, as observed on two floors. Medication bottles and injector pens lacked documented expiration and open dates. Staff admitted to not knowing the expiration dates, and the DON confirmed the expectation for staff to document these dates. The facility's policy requires identifying expiration dates and notifying the nurse manager if expired.
The facility failed to label medications according to professional standards, as observed on two floors and two medication carts. Unlabeled medication bottles and injector pens without documented open and discard dates were found. Staff acknowledged the oversight, and the facility's policy requires proper labeling to prevent contamination.
Failure to Honor Full Code Status and Initiate Timely CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s clearly documented Full Code status and to initiate CPR when the resident was found unresponsive. The resident had multiple medical diagnoses including type 2 diabetes, atrial fibrillation, abnormal gait, blindness in the right eye, shortness of breath, muscle wasting, mood disorder, and hypertension. On admission and throughout the stay, documentation in the EMR, physician orders, nursing assessments, care plan, and an APRN advance care planning note consistently identified the resident as Full Code, with the resident verbalizing understanding of Full Code versus DNR and electing Full Code. A 5‑day MDS showed intact cognition (BIMS 14), and progress notes shortly before the event documented the resident as clinically stable, at baseline, and continuing as Full Code. On the morning of the incident, a CNA assigned to the resident reported finding him unresponsive close to 6:00 a.m. and notified the LPN assigned to him. Another CNA reported being told around 5:30 a.m. that the resident was not responding and, upon entering the room, found the resident not breathing and without a pulse, partially hanging off the bed. Both CNAs described that when the LPN arrived, she checked the resident, left to obtain a pulse oximeter, returned with an oxygen saturation reading of 60, and was told by the CNA that there was no pulse and that a code should be called. The CNAs stated that the LPN delayed, left the room again to check code status, then reported the resident was Full Code, but still did not initiate CPR or call a code blue. Instead, the CNAs were sent to get another nurse from another floor, leaving the resident alone in the room during part of this time. The CNAs consistently reported that no staff initiated CPR before EMS arrived. The LPN assigned to the resident stated she found him unresponsive around 6:00 a.m., performed a sternal rub, noted he was not responding and that his feet were cold, and then left the room to call 911 from her personal cell phone and get the crash cart. She acknowledged that she did not start CPR, stating she believed the resident was already dead, that he was a large man, and that she needed a backboard and additional help to move him to the floor, but did not ask the CNAs to assist. She confirmed that no code blue was called and that no CPR was performed by facility staff. Two additional nurses who responded to the room reported they were summoned to “pronounce” a resident, assumed the resident was a DNR based on how the situation was presented, did not independently verify code status before acting, and did not initiate CPR. The RN who arrived stated she called the DON to ask what to do about pronouncing, was told the resident was Full Code and to start CPR, and that at that moment EMS arrived. EMS arrived at approximately 6:09 a.m., confirmed the resident’s Full Code status, questioned why CPR had not been started, and then initiated CPR, which continued for approximately 45 minutes before the resident was pronounced dead. Facility leadership and the Medical Director later confirmed that CPR had not been initiated by staff and that the resident’s Full Code status had not been honored, resulting in a determination of Immediate Jeopardy.
Removal Plan
- Initiated an internal investigation with resident record review, staff interviews, and notification to DCF, AHCA, and local law enforcement.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated two additional nurses who responded to the scene and reported their licenses to the licensing board.
- Completed a facility audit of resident code status preferences and verified that orders and care plans were correct.
- Conducted a 100% audit of the crash carts in the facility to ensure all required items were present.
- Held an Ad Hoc QAPI meeting with the Executive Director, Director of Clinical Services, and at least three other department heads.
- Reviewed facility deaths to ensure residents’ advance directives were followed related to code status.
- Implemented a requirement that licensed nursing staff sign a Honoring Advance Directive Attestation upon hire.
- Educated facility staff on Abuse, Neglect and Exploitation with emphasis on Advance Directives.
- Educated licensed staff on Honoring Advance Directives, timeliness of initiated CPR, following physician orders, and the Code Blue process.
- Provided all-staff Abuse, Neglect and Exploitation education with 100% completion.
- Provided all-staff Resident Rights education with 100% completion.
- Provided licensed nursing staff education with 100% completion on Honoring Advance Directives, Physicians Orders, timeliness of initiated CPR, and the Code Blue process.
- Conducted Code Blue quality assurance drills.
- Implemented a requirement that licensed nurses will not work prior to attending a mock Code Blue quality assurance drill.
- Interviewed staff members to confirm training and knowledge of code status policies, roles during a Code Blue, and where to find advance directives, and confirmed receipt of abuse and neglect training.
Failure to Honor Full Code Status and Initiate CPR for Unresponsive Resident
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly documented Full Code status by not initiating CPR when the resident was found unresponsive. The resident had multiple diagnoses including Type 2 diabetes, atrial fibrillation, abnormal gait, blindness in the right eye, shortness of breath, muscle wasting, mood disorder, and hypertension. On admission, the resident had no DNR order, was documented as alert, oriented, able to follow instructions, and capable of making healthcare decisions. Advance Care Planning notes from an APRN and a physician documented that the resident understood the difference between Full Code and DNR and elected/confirmed Full Code status. The admission evaluation, care plan, and subsequent physician notes all consistently reflected a Full Code status, and the resident’s cognition was documented as intact with a BIMS score of 14. On the night of the incident, CNAs and nursing staff described discovering the resident unresponsive in the early morning hours. One CNA reported being told by another CNA that her resident was not responding around 5:30 a.m. and, upon entering the room, found the resident not breathing and without a pulse. The CNA stated that the LPN assigned to the resident was notified but did not immediately come to the room, and when she did arrive, she used a pulse oximeter that showed an oxygen saturation of 60. The CNA reported that she repeatedly questioned the need to call a code and start CPR, but the LPN left the room to check the resident’s status and did not initiate CPR. The CNAs then went to obtain another nurse from another floor, leaving the resident alone in the room for a period of time. When they and additional nurses returned, the CNA reported that no one was performing CPR, no code blue was called, and 911 had not yet been contacted until directed by another RN. The LPN assigned to the resident stated that when notified by the CNA around 6:00 a.m., she found the resident unresponsive, with cold feet and no response to a sternal rub. She reported calling 911 from her personal cell phone at 6:04 a.m. and obtaining the crash cart, but acknowledged that she did not start CPR, stating she believed the resident was already dead, that he was a large person, and that she needed a backboard and help to move him to the floor. She also stated that she did not ask the CNAs to help move the resident and that no compressions were performed by her or the other nurses who arrived. Other nurses who responded to the scene reported that they were summoned under the impression that a resident needed to be pronounced dead, assumed the resident was a DNR, did not verify the code status themselves, did not call a code blue, and did not initiate CPR. The Medical Director later confirmed that the expectation for a Full Code resident found unresponsive was immediate initiation of CPR prior to EMS arrival and agreed that staff failed to honor the resident’s wishes for resuscitation. The surveyors determined that CPR was not initiated for approximately 35 minutes, resulting in physical pain and ultimate death for the resident and leading to an Immediate Jeopardy finding. Facility policies in place at the time required staff to follow American Heart Association guidelines for CPR, to provide basic life support including CPR prior to EMS arrival in accordance with the resident’s advance directives, and to ensure CPR-certified staff were available at all times. The policies also required clear communication of code status and adherence to residents’ rights to formulate advance directives. Despite these policies and the resident’s clearly documented Full Code status, staff did not call a code blue overhead, did not promptly verify and act on the code status, and did not initiate CPR while waiting for EMS. EMS personnel, upon arrival, questioned why CPR had not been started for a Full Code resident and then initiated resuscitative efforts themselves. The surveyors concluded that the failure to initiate CPR and honor the resident’s advance directive for end-of-life care created a situation that resulted in a worsened condition and the likelihood of serious injury and/or death, and they cited this as an Immediate Jeopardy deficiency.
Removal Plan
- Initiated an internal investigation including resident record review, staff interviews, and notification to DCF, AHCA, and local law enforcement.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated two additional nurses who responded to the scene and reported their licenses to the licensing board.
- Conducted a facility audit of resident code status preferences to verify orders and care plans were correct.
- Completed a full audit of the crash carts to ensure all required items were present.
- Held an Ad Hoc QAPI meeting with the Executive Director, Director of Clinical Services, Medical Director, and department heads.
- Placed overhead page system instructions by telephones at the nurse’s station, reception area, and dining room with instructions on how to page overhead.
- Reviewed facility deaths to ensure residents’ advance directives were followed related to code status.
- Completed an audit of licensed nurse licensure and verified CPR cards were valid.
- Implemented a requirement that all new employees participate in a Code Blue drill upon hire.
- Implemented a requirement that licensed nursing staff sign a Honoring Advance Directive Attestation upon hire.
- Educated facility staff on Resident Rights, including the right to choose code status.
- Educated licensed staff on honoring advance directives, timeliness of initiating CPR, following physician orders, and the Code Blue process.
- Provided all-staff education on abuse, neglect, and exploitation with full completion.
- Provided all-staff Resident Rights education with full completion.
- Provided licensed nursing staff education on honoring advance directives, physician orders, timeliness of initiating CPR, and the Code Blue process.
- Conducted Code Blue drill quality assurance drills.
- Implemented a requirement that licensed nurses will not work prior to attending a mock Code Blue drill.
- Conducted staff interviews to confirm training and knowledge of code status policies, Code Blue roles, where to find advance directives, and abuse and neglect training.
Failure to Initiate CPR and Honor Full Code Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff demonstrated competency in performing CPR and honoring a resident’s full code status. The resident involved had a documented physician progress note confirming that he understood the difference between full code and DNR and elected full code status. On the night of the incident, the resident was found unresponsive and without vital signs, yet facility staff did not initiate CPR. The facility’s LPN job description required current CPR certification and outlined responsibilities including directing CNAs, complying with policies and procedures, and participating in end-of-life care, but these expectations were not met in this event. According to interviews, a CNA who was not assigned to the resident was informed by the assigned CNA that the resident was not responding and not moving. As they proceeded to the room, they encountered the LPN at the nurses’ station, notified her of the situation, and the LPN stated she was on her way but continued what she was doing. When the LPN entered the room, she applied an oximeter and obtained an oxygen saturation of 60, which she described as “kind of low.” The CNA reported telling the LPN that the resident “is not here” and asking if they needed to call a code. The LPN left the room to check the resident’s code status, returned and confirmed he was full code, but still did not initiate CPR. The CNA stated that no one called a code blue, no overhead page was made, and no staff began CPR before EMS arrived. The LPN later stated she found the resident unresponsive, with cold feet and no response to sternal rub, and that she called 911, obtained the crash cart, and asked a CNA to get another nurse. She reported that she did not start CPR because she believed the resident was already dead, said she needed a backboard and help to move the resident due to his size, and did not ask the CNAs to assist. She acknowledged that she did not call a code, did not perform compressions, and that all staff present “did not do anything” while waiting for EMS. Other nurses who responded to the room, including an RN and another LPN, stated they did not start CPR, assumed the resident was a DNR based on how the situation was presented, did not verify the code status themselves, and did not call a code blue. The RN reported that she did not initiate CPR because she assumed the resident was a DNR and was focused on the idea that she was being asked to pronounce death, and only after contacting the DON did she learn the resident was full code and was told to start CPR, at which point EMS arrived. EMS personnel questioned why CPR had not been started if the resident was full code. The medical director stated that the expectation was that immediate CPR should be started for a full code resident and that nurses are not to pronounce death or rely on signs such as cold extremities, but instead should confirm code status and initiate CPR.
Removal Plan
- Initiated an internal investigation including resident record review, staff interviews, and notifications to DCF, AHCA, and local law enforcement.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated two additional nurses who responded to the scene and reported their licenses to the licensing board.
- Completed a facility-wide audit of resident code status preferences and verified that orders and care plans were correct.
- Reviewed residents with Do Not Resuscitate preferences to ensure a valid Florida DNRO was physically available at the facility.
- Conducted an audit of the facility’s crash carts to ensure all required items were present.
- Held an Ad Hoc QAPI meeting with the Executive Director, Director of Clinical Services, and Medical Director.
- Placed overhead paging system instructions by telephones at the nurse’s station, reception area, and dining room with instructions on how to page overhead.
- Reviewed facility deaths to ensure residents’ advance directives were followed related to code status.
- Completed an audit of licensed nurse licensure and verified cardiopulmonary resuscitation (CPR) cards were valid.
- Implemented a requirement that all new employees participate in a Code Blue drill upon hire.
- Implemented a requirement that licensed nursing staff sign an Honoring Advance Directive Attestation upon hire.
- Educated facility staff on Resident Rights, including the right to choose code status.
- Educated licensed staff on honoring advance directives, timeliness of initiating CPR, following physician orders, and the code blue process.
- Provided all-staff education on abuse, neglect, and exploitation.
- Provided all-staff Resident Rights education.
- Provided licensed nursing staff education on honoring advance directives, physician orders, timeliness of initiating CPR, and the code blue process.
- Conducted code blue quality assurance drills.
- Implemented a requirement that licensed nurses will not work prior to attending a mock code blue quality assurance drill.
- Conducted staff interviews to verify knowledge of facility policies regarding code status, roles during a code blue, and where to find advance directives, and confirmed staff received abuse and neglect training.
Incomplete ADL and Meal Documentation for Dependent, Incontinent Resident
Penalty
Summary
Surveyors identified a failure to maintain complete and accurate medical records for a resident with multiple diagnoses, including Parkinson's disease, sarcopenia, cognitive communication deficit, dementia, history of TIA, and cerebral infarction without residual deficits. The resident was admitted and discharged within a few days, and review of the toileting task documentation for that period showed no recorded incontinence care during 8 out of 10 opportunities. Review of the nutrition/eating task documentation for the same period showed no record that the resident received meals during 7 out of 9 opportunities. There were no documented refusals of care or meals. Staff interviewed on later dates did not remember the resident due to the short stay and could not describe the care provided. The DON stated she was not familiar with the resident and confirmed that documentation should verify whether care was provided or refused, and that there was no reason for care opportunities to be left blank. The resident’s MDS showed severe cognitive impairment (BIMS score of 04), dependence for toileting hygiene, and always incontinent for bowel and bladder. The care plan identified potential/actual skin integrity impairment related to decreased cognition, mobility, incontinence, pain, and weakness, with interventions to keep skin clean and dry. Facility policies on incontinence, ADLs, and serving meals required provision of appropriate toileting and nutritional care, but the facility did not provide a policy on documentation, and the existing record did not allow determination of whether incontinence care and meals were actually provided.
Deficiency in Kitchen Sanitation and Maintenance
Penalty
Summary
The facility failed to maintain kitchen equipment and surfaces in a clean and sanitary manner, as observed during a tour of the kitchen. The handwashing sink in the food preparation area was found on the floor, with exposed materials and an uncapped drainpipe, and had been out of service for approximately two weeks. The alternative sink in the dishwashing area was blocked by a dish rack cart, lacked paper towels, and had food debris partially blocking the water flow. Additionally, the commercial ice maker had visible dry white, tan, and black material around its perimeter and on its exterior surface, and the kitchen lighting was inadequate with several non-functioning fluorescent lights. The kitchen floor drain in the dessert area had standing liquid, and the industrial can opener was rusted with a black substance around the blade. The walk-in refrigerator and freezer contained a used glove, trash, and an open beverage can, with floors covered in a thick layer of black, grey, and brown substance. The bottom shelves of metal food preparation tables had rust spots and crumbs, and a sanitizing bucket contained cloudy liquid and food debris. The kitchen floor perimeters and areas under equipment had debris and dirt buildup, with sticky and discolored grout between tiles. Interviews with staff revealed that there was no schedule for deep cleaning the kitchen, and concerns were raised about the night shift not cleaning properly. The Dietary Supervisor confirmed that a cleaning schedule was posted but not consistently followed, and the Nursing Home Administrator acknowledged awareness of the sink issue. Despite documentation indicating that daily cleaning tasks were completed, observations and staff interviews contradicted this, highlighting a lack of adherence to cleaning protocols.
Plan Of Correction
The handwashing sink located in the food preparation area was repaired on by maintenance. The dishwashing area sink was cleaned, and no objects are blocking access to the sink. The paper towel dispenser was filled with paper towels, and a trash can was placed next to the sink. The commercial ice maker, ice storage bin, and floor were cleaned on. Kitchen lighting was replaced by maintenance on. The floor drain in the dessert prep area was cleaned, and the grate cover was replaced. An industrial can opener was purchased on and is cleaned daily and as needed. The walk-in refrigerator and freezer, including the floors, were cleaned on. The food preparation table, including bottom shelves, was cleaned. The red sanitizing bucket was emptied, and the kitchen floor, including perimeters, was cleaned. The Nursing Home Administrator and Dietary Manager completed a kitchen inspection and kitchen sanitation audit on. Any areas of concern were addressed as they were identified. On, the Nursing Home Administrator completed education with the Dietary Manager related to the components of this regulation, with emphasis on kitchen sanitation, ensuring a working handwashing sink was available in the kitchen and adequate lighting in the kitchen. Education was conducted on by the Nursing Home Administrator on the component of this regulation, with emphasis on maintaining proper sanitation standards throughout the food production and serving areas of the kitchen to include service tables that are clean, free from rust, working handwashing sinks, and adequate lighting. The Dietary Manager/designee will conduct a sanitation audit daily for one week, then weekly for a month, and every two weeks for two months. A report on sanitation audit results will be submitted by the Dietary Manager to the Quality Assessment and Assurance Committee monthly for one quarter until substantial compliance is met. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly. Quality monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services/designee.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure that all drugs used were labeled in accordance with clinical professional standards. During an inspection of a medication cart on two floors, it was observed that two translucent brown medication bottles had labels with spaces to write the medication expiration date and the date opened, but no information was filled in. Additionally, an injector pen was found with a label to document the 'date opened' and instructions to discard after 28 days, but these dates were not documented. Staff A, a Registered Nurse, admitted to not knowing the expiration dates for the medications and acknowledged that the labels should have been dated. Further inspection on the second floor revealed another injector pen without the open date and discard date listed. Staff B, an LPN, confirmed that the medication should be discarded 28 days after first use and immediately removed the injector pen from the cart. The Director of Nursing stated that the facility expects staff to write the medication expiration dates on the labels when medications are first used. The facility's policy on medication administration requires identifying expiration dates and notifying the nurse manager if medications are expired.
Plan Of Correction
Identified and injector pens were discarded on 04/23/2025. On 04/23/2025, new medications were provided by the pharmacy and dated appropriately. Quality review was conducted by the Director of Nursing/designee of current medication carts to ensure proper labeling/storage of drugs and biologicals, with emphasis on medications being dated at time of opening and discarding medication when expired. Any concerns noted were addressed as identified. Current Licensed Nurses were re-educated by the Director of Nursing/designee on the components of this regulation, with emphasis on ensuring proper labeling/storage of drugs and biologicals, with emphasis on medications being dated at time of opening and discarded at time of expiration. The Director of Nursing/designee will conduct quality monitoring of medication carts to ensure proper labeling/storage of drugs and biologicals, with emphasis on medications not being dated when opened and expired drugs twice weekly for 4 weeks, weekly for 2 weeks; then weekly and PRN as indicated. The findings of these quality monitoring activities will be reported to the Quality Assurance/Performance Improvement Committee monthly. The quality monitoring schedule will be modified based on findings, with quarterly monitoring by the Regional Director of Clinical Services/designee.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure that all drugs used were labeled in accordance with clinical professional standards. During an inspection of a medication cart on two floors, it was observed that two translucent brown medication bottles had labels with spaces to write the medication expiration date and the date the medication was first used, but no information was written on them. Additionally, an injector pen was found with a label to document the 'date opened' and instructions to discard after 28 days, but the necessary dates were not documented. Staff A, a Registered Nurse, admitted to not knowing the expiration dates and acknowledged that the labels should have been dated. Further observations on a second-floor medication storage cart revealed another injector pen without the open date and discard date listed. Staff B, an LPN, confirmed that the pen should be discarded 28 days after first use and immediately removed it from the cart. The Director of Nursing stated that the facility expects staff to write the medication expiration dates on the labels when medications are first used. The facility's policy on Medication Administration requires medications to be administered by licensed nurses in accordance with professional standards to prevent contamination, but this was not adhered to in these instances.
Plan Of Correction
Identified and injector pens were discarded on. New medications were provided by the pharmacy and dated appropriately. Quality review was conducted on, by Director of Nursing/designee, of current medication carts to ensure proper labeling/storage of drugs and biologicals with emphasis on medications being dated at time of opening and discarding medication when expired. Any concerns noted were addressed as identified. Current Licensed Nurses were re-educated by Director of Nursing/designee on the components of this regulation with emphasis on ensuring proper labeling/storage of drugs and biologicals with emphasis on medications being dated at time of opening and discarded at time of expiration. The Director of Nursing/designee to conduct quality monitoring of medication carts to ensure proper labeling/storage of drugs and biologicals with emphasis on medications not being dated when opened and expired drugs twice weekly x 4 weeks, weekly x 2 weeks; then weekly and PRN as indicated. The findings of these quality monitorings to be reported to the Quality Assurance/Performance improvement Committee monthly. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services/designee.
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.
