Pruitthealth-north Tampa, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lutz, Florida.
- Location
- 18940 Sunlake Blvd, Lutz, Florida 33558
- CMS Provider Number
- 106150
- Inspections on file
- 9
- Latest survey
- September 24, 2025
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Pruitthealth-north Tampa, Llc during CMS and state inspections, most recent first.
A staff member was assigned to CNA duties and provided direct resident care without verification of CNA certification or registry status. Facility leadership and HR staff were unaware of the lack of credentials, and the staff member was scheduled for multiple shifts in a CNA role, contrary to facility policy requiring active CNA certification.
Three residents with non-pressure skin conditions did not receive timely wound care, and their dressings were not dated as required. One resident's tracheostomy dressing was left unchanged for days after admission without proper orders, another had an undated neck dressing despite daily wound care orders, and a third had undated, visibly soiled bandages that were not promptly changed. Staff interviews and facility policy confirmed that dressings should be dated and changed if soiled, but these procedures were not consistently followed.
Three residents experienced significant delays in receiving prescribed pain medications, resulting in periods of uncontrolled pain. Issues included unavailable medications, delays in order entry, and lack of timely communication with providers. Staff interviews confirmed confusion about medication processes and failure to utilize available resources, leading to inadequate pain control.
The facility did not provide enough nursing staff to meet residents' needs for ADLs and meal assistance, resulting in family members and other residents stepping in to help with basic care tasks. Staff reported being unable to complete all required duties, and the restorative program was not operational. Facility leadership was unaware of the staffing shortfalls, and no staffing policy was provided.
Multiple newly admitted residents did not receive prescribed pain and essential medications for up to two days due to delays in pharmacy delivery, lack of staff training on medication dispensing systems, and insufficient communication with providers, resulting in unmanaged pain and missed doses of critical medications.
The facility did not ensure that residents and their representatives were properly informed about binding arbitration agreements or their right to refuse, resulting in several residents or their representatives signing agreements without adequate explanation or understanding. In some cases, residents with cognitive impairment signed without surrogate involvement, and others did not recall any discussion about arbitration.
Staff failed to follow infection prevention protocols, including not using PPE or performing hand hygiene when entering rooms with contact isolation signage, inconsistently cleaning reusable drinking cups, and not adhering to hand hygiene and aseptic technique during medication administration. Staff interviews revealed confusion about required practices, and there was no clear process for cup sanitation.
A resident with a history of antibiotic-resistant infection received IV Vancomycin without clear documentation of the infection type or diagnosis, and there was no use of McGreer's Criteria or contact precautions. Facility leadership confirmed that the antibiotic stewardship program was limited to color-coded charting and lacked systematic monitoring or infection control measures.
Surveyors observed that during a meal service, some residents were not served their meals at the same time as others at their table, and staff referred to residents needing assistance as "feeders" in a loud manner. Staff also failed to remove food items from trays before assisting residents, contrary to facility policy. Interviews confirmed these actions did not align with expected practices for maintaining resident dignity.
A resident with multiple complex medical conditions, including cognitive impairment, fall risk, and skin tears, was admitted without a baseline care plan being developed within 48 hours as required. Staff interviews revealed confusion over a recent process change assigning responsibility for care plan initiation to the admitting nurse, resulting in the omission.
A resident with Parkinson's disease and mobility issues reported increasing weakness and loss of endurance after being discharged from therapy, as staff did not provide the required supervision for walking. Interviews revealed that CNAs did not have time to assist and the restorative program was not operational, leaving the resident without needed support. The care plan was not updated to reflect these changes or the lack of restorative services, contrary to facility policy.
A resident with significant physical and cognitive impairments was not provided with needed meal assistance by staff, resulting in another resident feeding her during a meal. Staff interviews confirmed that help was not consistently given, and there was an assumption that family members would provide this care, despite facility policy and the resident's care plan requiring staff assistance.
Two residents received medications that were improperly crushed by an RN, including gabapentin and nifedipine extended-release, both of which were listed as 'do not crush' per facility policy and ISMP guidelines. The RN was unaware of the facility's list of medications that should not be crushed, resulting in a medication error rate of 8.0%, exceeding the acceptable threshold.
Surveyors found that medication and treatment carts were repeatedly left unlocked and unattended, with prescription and controlled drugs accessible and not properly secured. Medications were left on top of carts during administration, and medication carts were observed to be dirty. Staff interviews confirmed lapses in following facility policy for medication security and cleanliness.
The facility did not set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action, resulting in a lack of systematic review and follow-up on quality issues.
A resident with a nephrostomy tube did not receive appropriate care, as the dressing at the insertion site was not changed since hospital discharge and there were no physician orders for nephrostomy care. The DON was unable to describe the care provided, and the care plan lacked specific interventions for the nephrostomy tube, resulting in a deficiency in meeting professional standards.
The facility failed to properly monitor and care for surgical wounds in two residents, leading to deficiencies in wound care management. One resident had a left hip surgical site that was not consistently monitored for infection or staple removal, while another resident with a right femur fracture had delayed suture removal and inconsistent documentation of the surgical site. Interviews revealed that the facility's wound care nurse was not always available, and the facility's policy for wound care documentation was not consistently followed.
The facility failed to provide sufficient nursing staff, resulting in delayed responses to call lights and inadequate assistance with daily living activities. Residents reported non-functional call lights and reliance on family for care. Staff interviews revealed challenges due to staffing based on census rather than resident needs.
The facility failed to maintain a functioning nurse call system, with residents reporting non-operational call lights and ineffective table bells as alternatives. The Director of Maintenance was aware of the issue but did not conduct a complete audit, and the Nursing Home Administrator believed table bells sufficed for resident needs. The facility lacked a policy for Equipment Repair and Maintenance.
A resident was admitted to a facility with no musculoskeletal impairments noted, but later an X-ray revealed a fracture in the left femur. Despite this finding, the facility did not conduct an investigation into the cause of the fracture. The interim DON, who was covering multiple roles, did not interview staff or investigate the incident. It was later noted that the resident had falls at an ALF prior to admission, but this was not initially considered. The facility lacked a policy for conducting investigations.
The facility failed to ensure competent nursing care staff, particularly in the care of an unresponsive resident and wound monitoring for two other residents. A resident admitted for rehabilitation after a hip replacement was found on the floor and became unresponsive after being placed in a wheelchair. The LPN on duty left the resident to retrieve equipment, delaying response. Two other residents with surgical wounds had inconsistent documentation and monitoring, with delays in contacting physicians for staple and suture removal. The DON confirmed that surgical incisions should be monitored and documented until resolved.
Uncertified Staff Member Assigned to CNA Duties Without Verification
Penalty
Summary
The facility failed to ensure that a staff member assigned to Certified Nursing Assistant (CNA) duties was properly trained, certified, and listed on the CNA registry. Staff E was transferred from a dietary aide position to a CNA role and performed direct resident care duties without evidence of CNA licensure or registry verification. Review of Staff E's personnel file revealed no documentation of CNA certification, and background screening confirmed the absence of a professional license. Staffing assignment sheets showed that Staff E was regularly scheduled and assigned to provide direct care to residents in various rooms over multiple shifts. Interviews with facility leadership, including the Nursing Home Administrator (NHA), Regional Nurse Consultant (RNC), and Human Resource Manager (HRM), confirmed that Staff E had been working as a CNA without the required credentials. The NHA and RNC attributed the oversight to a lack of process and possible misconduct by a former HR staff member, who was later terminated for unrelated reasons. The current HRM and staffing coordinator were unaware of Staff E's lack of certification, and the facility's job description for the CNA position explicitly required active, unrestricted CNA certification.
Failure to Provide Timely Wound Care and Date Dressings
Penalty
Summary
The facility failed to provide timely wound care and ensure dressings were dated for three residents with non-pressure skin conditions. One resident was admitted with a tracheostomy stoma covered by a bandage dated from the hospital, which remained unchanged for two days after admission. There were no wound care orders in place upon admission, and the dressing was not assessed or changed until several days later. Staff interviews revealed confusion about who was responsible for entering wound care orders, and documentation confirmed that wound care was not performed or recorded until after a delay. Another resident was observed with an undated dressing on the left side of the neck, and the resident was unsure when the dressing had last been changed. Physician orders specified daily wound care, and the treatment administration record indicated that care was provided, but the dressings were not dated as required. Staff interviews confirmed that dressings should be dated and changed if soiled, but this was not consistently done. The facility's policy and wound care protocol both required documentation and dating of dressings, but these procedures were not followed. A third resident was observed with undated and visibly soiled bandages on the upper extremities, including a wet bandage with dark red liquid seeping onto the bed sheets. Orders were in place for regular wound care, but there was no documentation of the soiled bandages being addressed. Staff interviews indicated that bandages were not being dated and that soiled dressings were not changed promptly. The medical director and regional nurse both stated that bandages should be clean, dry, and dated, and that staff should notify the physician if dressings are repeatedly soiled, but these expectations were not met.
Failure to Provide Timely and Effective Pain Management
Penalty
Summary
The facility failed to ensure effective pain management for three residents who required such services, resulting in periods where pain was not controlled. One resident, admitted with multiple pain-related diagnoses including sepsis, cutaneous abscess, and spondylosis, did not receive prescribed pain medications for the first two days of admission. The resident reported pain at a level of 10 out of 10 and refused tube feedings due to severe discomfort. Medication administration records confirmed that several pain medications, including methadone, baclofen, morphine, and gabapentin, were either unavailable or not administered as ordered during this period. Staff interviews revealed confusion about the medication ordering process and delays in obtaining medications from the pharmacy or electronic dispensing machine. Another resident, admitted with a recent femur fracture and chronic pain, experienced a delay of a day and a half before receiving prescribed pain medication. During this time, the only pain relief provided was over-the-counter acetaminophen, which the resident reported as ineffective for severe pain experienced with movement. Review of records showed that the hospital discharge orders for stronger pain medications were not promptly entered into the facility's system, resulting in a delay in administration. A third resident, admitted for orthopedic aftercare and spinal stenosis, also experienced a delay of several days before receiving prescribed pain medications. The resident reported pain levels of 7-8 out of 10 and stated that only acetaminophen was available initially, which did not provide adequate relief. Medication administration records indicated that several ordered medications, including morphine and pregabalin, were not available or not administered as ordered. Staff interviews and physician statements confirmed issues with medication availability, order transcription errors, and lack of timely communication with providers regarding unavailable medications. The facility's own policy required regular pain assessments and prompt management, but these procedures were not followed, leading to unmanaged pain for the affected residents.
Insufficient Staffing for Resident Care and Meal Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, particularly in assisting with activities of daily living (ADLs) and meal assistance. Multiple interviews with residents, family members, and staff revealed that residents were not receiving adequate supervision or help with walking and meal times. One resident reported becoming weaker and losing endurance after being discharged from therapy, as no staff were available to supervise walking except during family visits. Staff members acknowledged that there were not enough CNAs to complete all required tasks, including range of motion exercises and walking assistance, and that the restorative program was not operational due to lack of oversight. Observations over several days showed family members and even other residents stepping in to assist with meals and coffee service in the dining area, indicating a lack of available staff during critical times. Family members expressed frustration at having to help with basic care tasks, and staff confirmed that families regularly assisted with meals due to insufficient staffing. Staff also described challenges in completing their work, especially during meal times, and noted that the number of residents needing assistance exceeded the available staff capacity. Interviews with facility leadership, including the staffing coordinator, DON, and administrator, revealed a lack of awareness or acknowledgment of staffing concerns, despite direct evidence from staff and families. The staffing coordinator based assignments on census and was unaware of specific needs during meal times, while the DON and administrator did not recognize any issues with staff coverage or the expectation for families to assist. Additionally, the facility was unable to provide a requested staffing policy and procedure.
Failure to Provide Timely Pharmaceutical Services for New Admissions
Penalty
Summary
The facility failed to ensure that newly admitted residents received their prescribed medications in a timely manner, resulting in multiple residents experiencing significant delays in pain management and other essential medications. Several residents reported not receiving their pain medications for up to two days after admission, despite having active orders for medications such as methadone, morphine, baclofen, gabapentin, oxycodone-acetaminophen, and pregabalin. Documentation in the Medication Administration Records (MAR) and interviews with residents and staff confirmed that medications were marked as unavailable, and residents experienced high levels of pain during this period. In some cases, only over-the-counter acetaminophen was administered, which residents reported as ineffective for their pain levels. Interviews with nursing staff revealed a lack of awareness and training regarding the use of the facility's electronic medication dispensing machine and backup pharmacy services, particularly during weekend admissions. Staff reported waiting for medications to arrive from the pharmacy and did not consistently utilize available emergency drug supplies or contact prescribing providers for alternative orders. There was also a lack of communication with the pain management physician and medical director regarding the unavailability of medications, and no evidence that responsible parties or providers were notified when medications were not administered as ordered. In addition to pain medications, at least one resident did not receive prescribed antihypertensive medications for two days, with documentation indicating the drugs were not available and the pharmacy had been notified. The facility was unable to provide a policy and procedure for pharmacy services when requested. The deficiency was further compounded by the facility's lack of a systematic process to ensure medication availability and administration upon admission, especially during weekends, as acknowledged by the nursing home administrator and consultant pharmacist.
Failure to Ensure Informed Consent for Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents and their representatives were properly informed about the contents of binding arbitration agreements and their right to refuse such agreements. For three sampled residents, documentation and interviews revealed that either the resident or their representative signed the arbitration agreement without adequate understanding or explanation of its terms. In one case, a resident with advanced dementia and a designated healthcare surrogate signed the agreement personally, despite medical documentation indicating the resident was unable to provide meaningful information and required a surrogate for decision-making. The surrogate confirmed not being present or involved in the signing process. In another instance, an alert and oriented resident and their spouse did not recall any discussion or explanation regarding arbitration, despite the agreement being signed. Similarly, a third resident and their representative, who was the power of attorney, did not recall signing or having the arbitration agreement explained to them. Interviews with facility staff, including the Senior Nurse Navigator and the Nursing Home Administrator, confirmed that the process should involve reviewing and explaining the arbitration agreement to the resident or their representative, ensuring understanding, and informing them of their right to refuse. However, the facility did not have a specific policy regarding arbitration agreements, and the documented process was not consistently followed, as evidenced by the lack of informed consent and understanding among the sampled residents and their representatives.
Failure to Implement and Maintain Infection Prevention and Control Program
Penalty
Summary
Surveyors observed multiple failures in the implementation and maintenance of the facility's infection prevention and control program. Staff were seen not adhering to posted contact isolation precautions, including not donning personal protective equipment (PPE) such as gowns and gloves when entering rooms with contact isolation signage, and not performing hand hygiene before and after resident contact or between tasks. For example, an occupational therapist and several certified nursing assistants (CNAs) entered and exited rooms with contact isolation signage, assisted residents, delivered meal trays, and touched resident environments without using PPE or performing hand hygiene. Staff interviews revealed a lack of understanding regarding when PPE and hand hygiene were required, with some staff believing these precautions were only necessary during specific care activities, such as toileting, rather than for all resident contact or environmental interaction as indicated by facility policy and CDC guidelines. Additionally, the facility failed to ensure proper cleaning and sanitation of reusable resident drinking cups. Residents and staff reported inconsistent cleaning practices, with some cups being washed in resident room sinks or nourishment rooms using hand soap and water, and others sporadically sent to the kitchen for dish machine cleaning. There was no established or communicated schedule for cup sanitation, and staff were unclear about the process. The registered dietitian and director of nursing were not aware of the specific cleaning schedule, and staff provided conflicting information about cup handling and cleaning responsibilities. Further deficiencies were noted during medication administration. Nursing staff, including LPNs and RNs, were observed not performing hand hygiene before preparing or administering medications, and not changing gloves or using hand sanitizer as required by facility policy. In one instance, an RN dropped IV tubing on the floor, picked it up, and proceeded to use it without replacing it, contrary to facility expectations. Interviews with staff and the DON confirmed that these actions did not align with facility policy, which requires aseptic technique and hand hygiene during medication administration and when handling IV equipment.
Failure to Implement Antibiotic Stewardship and Monitoring
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of a system to monitor antibiotic use and antibiotic-resistant organisms for a resident admitted with a history of Methicillin-resistant Staphylococcus aureus and an unspecified bacterial infection. Review of the resident's Medication Administration Record (MAR) showed administration of intravenous Vancomycin over several weeks, but there was no documentation specifying the reason for the antibiotic, the type of infection being treated, or a corresponding diagnosis. Physician orders did not include contact precautions, and there was no use of McGreer's Criteria to monitor or classify the infection. Interviews with facility leadership revealed that the antibiotic stewardship program consisted only of color-coded charting of residents on antibiotics, without systematic tracking or use of standardized criteria. The Director of Nursing confirmed that McGreer's Criteria were not in use for monitoring, and the Nursing Home Administrator stated that there was no established infection control or antibiotic monitoring program in place at the time of the resident's admission and treatment. The facility's policy required an antibiotic stewardship program, but it was not effectively implemented or maintained.
Failure to Maintain Resident Dignity During Dining Service
Penalty
Summary
During a lunch meal service in the dining room between the 400 and 500 hallways, surveyors observed that the facility failed to maintain resident dignity during dining. Multiple residents were seated at tables where not all individuals received their meals at the same time, resulting in some residents waiting while others began eating. Staff were seen assisting residents with eating without removing food items from the trays, contrary to facility policy. Additionally, staff referred to residents needing assistance as "feeders" in a loud manner that was audible to other residents and visitors, further compromising resident dignity. Interviews with staff confirmed that all residents at a table should be served simultaneously, food should be removed from trays before serving, and residents should not be referred to as "feeders." The facility's dining policy also specifies that plates, side dishes, and drinks should be removed from trays and placed on the table, and that domes, lids, and trays should be cleared away. The administrator stated there was no specific policy on dignity, but that the facility follows regulatory requirements.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. The resident was admitted with multiple diagnoses, including metabolic encephalopathy, mood disorder, anxiety disorder, difficulty walking, cognitive communication deficit, left hip osteoarthritis, cognitive impairment, and a history of falls. Documentation showed the resident had impaired hearing, generalized weakness, a urinary tract infection, lactic acidosis, incontinence, a need for two-person assistance with transfers, and skin tears on both the left upper and right lower extremities. The resident was also identified as high risk for falls based on the Morse Fall Risk score. Interviews with facility staff revealed that the responsibility for completing baseline care plans had recently shifted from the MDS Director to the admitting nurse, but not all nurses understood the new process. The MDS Director and DON both confirmed that a baseline care plan had not been completed for the resident within the required timeframe. Despite requests, no baseline care plan was provided for the resident, and staff acknowledged the process change and the additional time required to complete the care plan. The facility's policy required a baseline care plan to be initiated within 24 hours and completed within 48 hours of admission, but this was not followed in this case.
Failure to Update ADL Care Plan After Therapy Discharge
Penalty
Summary
The facility failed to revise the Activities of Daily Living (ADL) care plan to reflect a resident's current condition following discharge from therapy. The resident, who has diagnoses including Parkinson's disease, difficulty in walking, and other comorbidities, reported feeling weaker and losing endurance since therapy ended, stating that no staff were available to supervise her walking except during family visits. Therapy had instructed the resident to ensure supervision while walking, but this was not consistently provided after discharge from therapy. Interviews with staff revealed that Certified Nursing Assistants (CNAs) did not have time to assist with walking or range of motion exercises, and these tasks were typically assigned to a restorative aide. However, the restorative aide position had not been filled, and the restorative program was not operational, leaving no one to oversee or provide the necessary support. The Director of Rehabilitative Services confirmed that although the resident was discharged from therapy with a home exercise program, the facility lacked a restorative program and staff to implement it. A review of the resident's care plan showed it had not been updated to address the resident's current needs or the lack of restorative services. The care plan continued to list general approaches such as providing assistive devices and encouraging independence, but did not reflect the resident's need for supervised walking or the absence of restorative support. Facility policy requires care plans to be updated with any change in condition, but this was not done in this case.
Failure to Provide Required Meal Assistance
Penalty
Summary
A deficiency occurred when a resident who required assistance with eating was not provided the necessary help by facility staff during a meal. Observation showed another resident feeding the affected resident, stating that if she did not help, no one else would. The resident in question had a history of muscle weakness, hand contractures, dysphagia, and moderate cognitive impairment, and her care plan specifically indicated the need for assistance with feeding at meals. Multiple records, including progress notes and nutritional assessments, confirmed her ongoing need for meal assistance due to her physical limitations and recent decline in self-feeding ability. Interviews with staff revealed that assistance was not consistently provided, with one CNA stating she only helped after distributing trays and that the resident's family member usually provided the help. The DON acknowledged that while staff are responsible for meal assistance, there was an assumption that family members would be present to help during mealtimes. Facility policy emphasized the importance of providing competent and respectful care for activities of daily living, including eating, but this was not followed in the observed instance.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Crushing of Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required. During medication administration observations, two errors were identified out of twenty-five opportunities, resulting in an 8.0% error rate. In one instance, a registered nurse crushed and administered gabapentin, which is listed by the facility and the Institute of Safe Medication Practices (ISMP) as a medication that should not be crushed. In another instance, the same nurse crushed and administered nifedipine extended-release, despite the medication administration history specifically stating 'DO NOT CRUSH' as a special instruction. The nurse also crushed other medications for the same resident, including calcium carbonate, buspirone, and vitamin D3. Interviews revealed that the nurse was unaware of where to find the facility's list of medications that should not be crushed. The facility's policy on medication administration requires staff to follow physician orders, pharmacy instructions, and facility policy, including not crushing long-acting or enteric-coated dosage forms unless specifically ordered by a physician. The Director of Nursing confirmed that staff are expected to be familiar with these requirements. The failure to adhere to these protocols directly contributed to the identified medication errors.
Medication Storage and Security Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the facility's medication storage and handling practices across several halls. Unlocked and unattended medication and treatment carts containing prescription medications were found on multiple occasions, with no staff present in the vicinity. Controlled drugs stored in an emergency drug kit were not kept in a permanently affixed compartment as required, and staff were unaware of proper storage protocols. Additionally, medications, including IV antibiotics and various oral medications, were left unattended on top of medication carts during administration, and staff admitted to forgetting to lock the carts or mistakenly believing it was acceptable due to the presence of a surveyor. Further observations revealed that medication carts were not maintained in a clean condition, with sticky, gummy residue found in the drawers of carts on different halls. Staff interviews confirmed that nurses are responsible for cleaning the carts and that medication carts should be locked and not left unattended. The facility's own policy requires that medication storage areas be locked or attended by authorized personnel and kept clean and organized, but these procedures were not consistently followed as evidenced by the survey findings.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process to identify, analyze, and address quality issues within the facility. The lack of such a group meant that quality deficiencies were not consistently reviewed or acted upon, as required.
Failure to Provide Nephrostomy Tube Care per Standards
Penalty
Summary
The facility failed to provide appropriate nephrostomy care and services consistent with professional standards of practice for a resident with multiple urological diagnoses, including obstructive and reflux uropathy, chronic kidney disease, and hydronephrosis. Upon observation, the resident's nephrostomy insertion site dressing was found to be not intact and had not been changed since before admission, as confirmed by the resident, who stated the last dressing change occurred at the hospital. The resident reported asking a nurse to change the dressing but was told there were no orders to do so. The urine in the nephrostomy bag appeared serosanguinous. Review of the medical record revealed no physician orders related to nephrostomy tube care, and the care plan did not include specific interventions for dressing changes or tube flushing. During interviews, the DON was unable to describe the care provided for the nephrostomy tube and acknowledged that orders for care had not been obtained. The facility's care plans addressed infection prevention and catheter care in general terms but did not specify nephrostomy tube management. Professional standards recommend changing the nephrostomy dressing at least every seven days or sooner if soiled or wet, which was not followed in this case. The lack of physician orders and failure to provide timely dressing changes led to the deficiency in care for the resident's nephrostomy tube.
Deficiencies in Surgical Wound Monitoring and Care
Penalty
Summary
The facility failed to ensure proper monitoring and care of surgical wounds for two residents, leading to deficiencies in wound care management. Resident #1 was admitted with a left hip surgical site and a left ankle skin tear. Despite having a physician's order for a portable x-ray due to pain, the facility did not consistently monitor the surgical site for signs of infection or follow up on the removal of surgical staples. The resident's skin assessments were inconsistent, and there was a lack of documentation regarding the condition of the surgical incision, which was not monitored from the resident's return to the facility until a later date. Resident #7 was admitted with multiple incisions related to a right femur fracture. The facility failed to document the appearance of the surgical incision and the number of staples present. Despite the resident experiencing discomfort and signs of erythema at the surgical site, the facility did not consistently monitor the site or document the condition of the incision. The removal of sutures was delayed, and there was a lack of daily monitoring of the surgical site, as evidenced by the absence of documentation in the resident's clinical record. Interviews with staff, including the Director of Nursing, revealed that the facility had a wound care nurse who was not always available to focus solely on wound care. The facility's policy required documentation of skin and wound care, including weekly assessments and monitoring of surgical sites, but these procedures were not consistently followed. The lack of adherence to the facility's policy and the inconsistent monitoring and documentation of surgical wounds contributed to the deficiencies identified in the care of these residents.
Inadequate Staffing and Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple instances of delayed response to call lights and inadequate assistance with activities of daily living. Resident #9 reported that their call bell had not worked since admission, and despite being provided with a metal table bell, staff did not respond when it was rung. This resident expressed feeling unsafe due to the lack of timely assistance. Similarly, Resident #13 and their representative reported that the call light was ineffective, and assistance was only available when the representative was present. Resident #8's representative also noted that the call light was not functional and that they had to personally assist the resident due to the lack of staff response. The facility's grievance logs revealed multiple complaints related to insufficient assistance with daily care needs, such as hearing aid assistance, meal setup, and personal hygiene. These grievances highlighted a pattern of neglect in addressing residents' needs, with some residents resorting to calling family members for help. Observations confirmed that call lights were not being answered promptly, with one instance showing a 15-minute delay before a therapist entered a room after a call light was activated. Interviews with staff members, including CNAs and the Staffing Coordinator, indicated that staffing levels were determined based on census rather than the specific needs of residents. Staff members expressed challenges in managing their assignments due to the facility's layout and the number of residents requiring care. The facility's policy on staffing emphasized the need for adequate staff to ensure residents' health, safety, and welfare, but the observed practices did not align with this policy, leading to the identified deficiencies.
Failure to Maintain Functioning Nurse Call System
Penalty
Summary
The facility failed to maintain a functioning nurse call system, which was observed to be non-operational during a two-day survey. Residents reported that their call lights were not working, and they were provided with table bells as an alternative, which were also ineffective in summoning assistance. Resident #9 and Resident #8's representative both confirmed the call lights were not functioning, and the table bells provided did not result in timely assistance. The Director of Nursing initially claimed all systems were functional, but later acknowledged awareness of the issue in some rooms. The Director of Maintenance (DOM) admitted to being aware of the malfunctioning call lights in certain rooms and had issued table bells as a temporary solution. However, a complete facility audit was not conducted, and only a sampling of rooms was checked weekly. The DOM demonstrated altering the logbook documentation, changing a 'Fail' to 'Pass', which was claimed to be an error. Staff members, including a Registered Nurse, reported the issue to administration, but not all affected residents received table bells due to a shortage. The Nursing Home Administrator (NHA) stated that a vendor was contacted for repairs, but the facility was busy due to recent hurricanes. The NHA believed that providing table bells met the requirement for residents to notify staff of their needs. However, the facility lacked a policy and procedure for Equipment Repair and Maintenance, contributing to the ongoing issue with the nurse call system.
Failure to Investigate Fracture of Unknown Origin
Penalty
Summary
The facility failed to conduct an investigation into a fracture of unknown origin for a resident. The resident was admitted from the hospital with various diagnoses, including urinary tract infection and vascular dementia, and was assessed to have no musculoskeletal impairments upon admission. However, an X-ray ordered due to complaints of pain revealed a fracture in the left femur, leading to the resident being sent to the hospital. Despite the discovery of the fracture, no investigation was conducted by the facility to determine its cause. Interviews with staff revealed that the interim Director of Nursing, who was also covering multiple roles, did not conduct interviews or investigate the incident. It was later mentioned that the resident had experienced falls at an assisted living facility prior to hospital admission, but this information was not initially considered. The facility's policy on patient abuse and neglect did not include guidelines for conducting investigations, and the Director of Nursing confirmed the absence of such a policy.
Inadequate Nursing Competency and Wound Monitoring
Penalty
Summary
The facility failed to ensure competent nursing care staff, particularly in the care of an unresponsive resident and wound monitoring for two other residents. Resident #10, who was admitted for rehabilitation after a hip replacement, was found on the floor by a CNA. The resident was initially responsive but became unresponsive after being placed in a wheelchair. The LPN on duty, Staff G, left the resident to retrieve a vital signs machine, during which time the resident became unresponsive. CPR was initiated, but there was a delay in response as Staff G left the unit to get another nurse, Staff P, who confirmed that the resident was unresponsive and CPR was needed. The Director of Nursing (DON) stated that the resident should have been left on the floor and 911 called immediately, and that the nurse should not have left the resident alone. Resident #1's care was also deficient in terms of wound monitoring. The resident was admitted with a hip fracture and had a surgical site with 19 staples. However, the facility's documentation was inconsistent, with some records failing to note the presence of the surgical incision or the condition of the skin. The resident's MAR did not show consistent monitoring of the surgical site for signs of infection, and there was a delay in contacting the correct surgeon for staple removal. The DON acknowledged that the incision should have been monitored until the staples were removed, and that staff should have reached out to the physician sooner. Resident #7 also experienced inadequate wound monitoring. The resident had a right femur fracture with multiple surgical incisions, but the facility's documentation was inconsistent, with some notes failing to describe the appearance of the surgical incision or the number of staples present. The resident's MAR did not show daily monitoring of the surgical site, and there was a delay in obtaining orders for suture removal. The DON confirmed that surgical incisions should be considered an alteration in skin until resolved and should be documented accordingly. The facility's policy on skin and wound care documentation was not consistently followed, leading to gaps in the monitoring and care of residents' wounds.
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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