Rehabilitation And Healthcare Center Of Tampa
Inspection history, citations, penalties and survey trends for this long-term care facility in Tampa, Florida.
- Location
- 4411 N Habana Ave, Tampa, Florida 33614
- CMS Provider Number
- 105234
- Inspections on file
- 30
- Latest survey
- April 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Rehabilitation And Healthcare Center Of Tampa during CMS and state inspections, most recent first.
The facility failed to ensure smoking safety for three residents, leading to a deficiency in maintaining a safe environment. A resident was found with smoking materials in her room, and two others were observed smoking without proper supervision. Staff interviews revealed inconsistencies in smoking supervision and a lack of documented assessments for smoking safety measures.
A resident undergoing dialysis had an inaccurate care plan that failed to reflect a physician-ordered fluid restriction and omitted the resident's desired discharge location. The MDS coordinator and Social Services Director acknowledged these discrepancies, which were not in line with the facility's care plan policy.
The facility did not ensure accurate PASRR evaluations for two residents with serious mental illnesses and dementia. One resident had diagnoses including schizophrenia and dementia, but a Level II PASRR was not completed. Another resident with similar conditions also did not receive the necessary Level II evaluation. Staff interviews confirmed these oversights, which were contrary to the facility's policy requiring such evaluations.
A resident dependent on staff for all ADLs due to multiple health conditions was primarily cared for by private sitters hired by the family, rather than CNAs as required by the care plan. The sitters performed tasks such as turning, incontinence care, and range of motion exercises without consistent oversight from facility staff, and the NHA was unaware of the extent of their involvement. The facility's policy did not mandate these sitters to provide necessary care, leading to a deficiency in ensuring qualified care.
Two residents in an LTC facility were not provided with individualized activities, leading to a deficiency in enhancing their quality of life. One resident, weakened by cancer treatments, was not offered bedside activities despite a care plan indicating the need for staff assistance. Another resident, who only spoke Creole, was left without activities and had a care plan that was not followed due to language barriers. The facility's policy on activities was not adhered to, resulting in a failure to meet the residents' individual needs.
The facility failed to provide necessary emergency tracheostomy supplies for three residents, leading to deficiencies in respiratory care. A resident did not have the required tracheostomy set in their room, another resident's room lacked essential respiratory care equipment, and a third resident's suction canister was nearly full with no replacement available. The facility's policies and physician orders were not followed, indicating a failure to maintain adequate respiratory supplies.
A resident with severe cognitive impairment and requiring substantial assistance fell from bed during care, resulting in a scalp hematoma and clavicle fracture. The CNA attempted to provide care alone, despite the care plan indicating the need for two-person assistance. The incident occurred when the resident rolled out of bed while the CNA was calling for help. The facility investigated the incident and provided staff education on abuse, neglect, exploitation, and misappropriation.
The facility failed to ensure a safe, clean, and homelike environment for residents on the 3rd and 4th floors. Observations revealed lifting flooring and damaged walls in rooms 409 and 311-B, which were not reported or addressed in a timely manner. Staff interviews indicated a lack of awareness and communication regarding these maintenance concerns.
The facility failed to ensure accurate resident assessments and discharge documentation for three residents. Two residents were observed with bed rails up, contrary to their MDS assessments, and another resident's discharge status was inaccurately documented as being sent to a hospital instead of home.
The facility failed to obtain informed consent and properly assess bedrail use for three residents, leading to the installation of bedrails without documented alternative methods or consent. Observations and interviews revealed that the residents' care plans and medical records did not reflect the use of bedrails, and staff were uncertain about the assessment process.
A facility failed to provide a necessary mobility device for a resident with Multiple Sclerosis, obesity, and Lupus Erythematosus. Despite the resident's care plan indicating the need for a high back wheelchair and her quarterly MDS assessment showing recent use of a wheelchair, the resident was left without one. Interviews with staff revealed inconsistencies and a lack of clarity regarding the provision of the wheelchair.
A resident with intact cognition reported missing clothes multiple times, but the facility failed to resolve the grievance to the resident's satisfaction. Despite filing an official grievance and the facility's attempts to address the issue, the resident remained dissatisfied with the response and continued to report missing items.
The facility failed to ensure accurate Level I PASRR assessments for three residents with serious mental illness and dementia, leading to missed Level II evaluations. Errors were acknowledged by the DON and Social Service Director, who cited confusion during the PASRR completion process.
The facility failed to update a resident's care plan after the discontinuation of a physician's order for a foot brace. Despite the resident's cognitive intactness and confirmation of not wanting to wear the shoe, the care plan still included outdated interventions. Interviews with staff revealed that the care plan should have been revised to reflect the resident's current health status.
A resident with an ADL self-care performance deficit did not receive necessary nail care despite requests and visible need. The facility lacked clear guidelines, and staff were unclear about their responsibilities regarding nail care.
The facility failed to ensure active and ongoing communication with hospice providers for two residents, resulting in missing hospice notes in medical records and inadequate pain management for a resident with Alzheimer's Disease. Staff interviews and observations confirmed the lack of proper documentation and communication, breaching the facility's Hospice Agreement.
The facility failed to maintain a medication error rate of less than 5%, resulting in a 7.41% error rate. Two residents received incorrect medications due to a nurse's failure to verify the correct dosages and types as per physician's orders.
Inadequate Smoking Safety Measures and Supervision
Penalty
Summary
The facility failed to ensure a process was in place for smoking safety for three residents, leading to a deficiency in maintaining a safe environment free from accident hazards. Resident #8 was observed with cigarettes and a lighter in her room, despite not being listed as an active smoker in the facility's records. She admitted to occasionally smoking outside the designated smoking area and providing cigarettes and lighters to other residents. This indicates a lack of supervision and control over smoking materials within the facility. Resident #29 was seen with a lighter while waiting to access the smoking patio, and during a scheduled smoking time, no staff or residents were present in the designated area. This suggests inadequate supervision during smoking times, as well as a failure to adhere to the facility's smoking policy, which requires staff supervision during smoking activities. Resident #164 was observed smoking on the patio without staff presence, further highlighting the lack of supervision and adherence to safety protocols. Interviews with staff revealed inconsistencies in the smoking supervision process and a lack of clear assessment procedures for determining residents' need for smoking safety measures, such as aprons. The Director of Nursing admitted that there was no formal smoking assessment documented, and observations of smoking sessions were not recorded. The facility's policy mandates that smoking materials be kept in a secure location and that residents should not possess them within the building, yet this was not enforced, contributing to the deficiency.
Inaccurate Care Plan for Dialysis Resident
Penalty
Summary
The facility failed to ensure an accurate comprehensive care plan for a resident undergoing dialysis. The resident, who was admitted and readmitted with diagnoses including acute respiratory failure and end-stage renal disease, was observed to have a care plan that inaccurately reflected his fluid restriction status. Despite having a physician order for a 1200 cc fluid restriction, the care plan incorrectly marked fluid restriction as 'no'. This discrepancy was acknowledged by the MDS coordinator, who confirmed that the care plan needed correction to align with the physician's orders. Additionally, the discharge planning section of the resident's care plan was incomplete. The resident expressed a desire to be discharged to a facility closer to his girlfriend, a preference he had communicated to the staff. However, this information was not documented in the care plan. The Social Services Director confirmed that the discharge location should have been included in the care plan and acknowledged the need for correction. The facility's policy mandates that discharge planning be part of the care plan process, which was not adhered to in this case.
Inaccurate PASRR Evaluations for Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASRR) for two residents, leading to deficiencies in their care. Resident #67 was initially admitted with diagnoses including unspecified dementia, depressive episodes, schizophrenia, and unspecified psychosis. Despite these diagnoses, the Level I PASRR did not indicate the need for a Level II evaluation, which was incorrect according to the facility's staff. The resident's care plan included interventions for behavioral issues and psychotropic medication management, but the oversight in PASRR evaluation meant that the necessary Level II PASRR was not completed, as confirmed by Staff A during an interview. Similarly, Resident #75 was admitted with multiple diagnoses, including mood disorder, dementia, schizophrenia, and anxiety disorder. The Level I PASRR for this resident also failed to trigger a Level II evaluation, despite the presence of serious mental illness and dementia. Interviews with the Social Services Director and Assistant confirmed that a Level II evaluation was required but not completed. The facility's policy mandates a review of PASRR forms for serious mental illness and intellectual disability, which was not adhered to in these cases, resulting in the deficiency.
Deficiency in Qualified Care Provision for Resident
Penalty
Summary
The facility failed to ensure that services provided to a resident were performed by individuals with the necessary skills, experience, knowledge, and licensure. This deficiency was observed in the care of a resident who was dependent on staff for all activities of daily living (ADL) due to multiple health conditions, including a tracheostomy, dementia, and chronic kidney disease. The resident's care plan required assistance from two staff members for ADLs, yet observations revealed that private sitters hired by the family were performing these tasks without the involvement of certified nursing assistants (CNAs) as required by the care plan. Interviews with the private sitters indicated that they were responsible for the resident's ADL care, including turning the resident, providing incontinence care, and performing range of motion exercises. The sitters were not consistently monitored or supported by facility staff, and the Nursing Home Administrator was unaware of the extent of care being provided by these sitters. The facility's policy on visitation and essential caregivers did not require these sitters to provide necessary care, highlighting a gap in ensuring that care was delivered by qualified personnel as per the resident's care plan.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing activity program that met the individual interests and needs of two residents, leading to a deficiency in enhancing their quality of life. Resident #154, who preferred to stay in bed due to weakness from recent cancer treatments, expressed a desire to participate in activities but was not offered bedside activities by the facility staff. Despite having a care plan that included participation in activities of choice and requiring staff assistance, there was no documentation of Resident #154's participation in group or individual activities throughout the month. The Activities Director admitted that one-on-one activities were not documented in the resident's medical record, and the weekly activity log did not include Resident #154's name. Resident #472, who only spoke Creole, was observed lying in bed throughout the day without being provided activities, with the television on an English-speaking program. The resident's care plan indicated a need for assistance with activities due to cognitive deficits and required physical assistance. However, the Activities Director was unaware of the resident's language needs and had not implemented a process to ensure that room visits were conducted or that activity interventions were followed. The resident's representative confirmed that the resident only understood Creole and expressed a desire for the resident to be more involved in activities. The Director of Nursing stated that all residents should be offered the opportunity to participate in activities, and if a resident refused, it should be documented with follow-up to encourage involvement. The facility's policy on activities emphasized the need for sensitivity and understanding of each resident's individual needs, including medical, emotional, spiritual, therapeutic, and recreational needs. However, the facility failed to adhere to this policy, resulting in a deficiency in providing appropriate activities for the residents.
Deficiency in Respiratory Care Due to Lack of Supplies
Penalty
Summary
The facility failed to provide necessary emergency tracheostomy supplies for three residents, leading to deficiencies in respiratory care. Resident #142 did not have the required tracheostomy set of the same size and a smaller size in their room, as confirmed by Staff E, RN/UM. The resident's care plan and physician orders specified the need for an ambu bag and replacement trach at the bedside, which were not present during the observation. Resident #25's room was found lacking essential respiratory care equipment, including a dry humidifier bottle and missing suction catheters. The resident's physician orders required continuous humidified oxygen, which was not being administered as prescribed. Staff O, RN, was unable to locate the necessary equipment, indicating a failure to adhere to the care plan and physician orders. Resident #156's suction canister was observed to be nearly full with a dark pink liquid, and no replacement canister was available in the room. Staff P, RN, had to leave the floor to obtain a new canister, highlighting a lack of readily available supplies. The facility's policy required changing the suction canister every 72 hours or when 3/4 full, which was not followed. Additionally, the supply closet on the floor was found to be lacking extra canisters and suction catheters, further demonstrating the facility's failure to maintain adequate respiratory supplies for residents with tracheostomy needs.
Resident Fall Due to Inadequate Assistance
Penalty
Summary
The facility failed to prevent a fall resulting in injury to a resident who had severe cognitive impairment and required substantial assistance with activities of daily living. The resident, who had been admitted to the facility in 2017, had a history of dementia, muscle wasting, and lack of coordination, among other conditions. The care plan for the resident indicated the need for a total mechanical lift with two-person assistance for transfers and two-person assistance for bed mobility. However, during an incident on 07/16/2024, a CNA attempted to provide care alone, which led to the resident rolling out of bed and sustaining injuries. On the day of the incident, the CNA was providing evening care and noticed the resident had a large bowel movement. The CNA rolled the resident onto her side to clean her, but the resident rolled out of bed before the CNA could stop her. The CNA had called out for assistance but did not receive help in time. The resident fell to the floor, resulting in a scalp hematoma and a clavicle fracture. The CNA reported that the resident had never rolled out of bed before, and the bed was raised to an ergonomic height for care. Interviews with staff revealed that the resident was known to require two-person assistance for care, especially when being cleaned. The Nursing Home Administrator confirmed that the CNA initially thought she could manage the care alone but called for help when realizing the extent of the task. The incident was investigated, and it was determined that the fall was unsubstantiated for neglect, although staff received education on abuse, neglect, exploitation, and misappropriation following the event.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents on the 3rd and 4th floors. Observations revealed that the flooring in room 409 was lifting and could be freely moved, posing a potential hazard. Additionally, the wall behind bed B in room 409 had several deep scratch marks with missing paint and visible debris on the floor. Despite the facility's electronic maintenance system and concierge rounds, these issues were not reported or addressed in a timely manner. Interviews with staff, including the Nursing Home Administrator (NHA), Registered Nurse (RN) Unit Manager (UM), and Maintenance Assistant (MA), indicated a lack of awareness and communication regarding the maintenance concerns in room 409. The NHA and RN UM were unsure if the maintenance staff were aware of the issues, and the MA only became aware of the flooring concern on 5/16/2024. The Director of Nursing (DON) confirmed that environmental or maintenance concerns should be documented in the facility's electronic maintenance log, but this process was not effectively followed. Further observations in room 311-B revealed damaged walls with patches of paint coming off and deep scratches. Staff interviews indicated that daily inspections by Certified Nursing Assistants (CNAs) and Unit Managers were supposed to identify such concerns, but the damaged walls in room 311-B were not noticed or reported. The facility's policy on maintaining a safe, clean, and comfortable environment was not adhered to, as evidenced by the unaddressed maintenance issues in the resident rooms.
Inaccurate Resident Assessments and Discharge Documentation
Penalty
Summary
The facility failed to ensure the accuracy of resident comprehensive assessments for three residents. Resident #64 was observed with bilateral, one-quarter length bed rails up, despite the quarterly Minimum Data Set (MDS) assessment indicating that bed rails were not used. This discrepancy was confirmed through multiple observations and interviews with the resident's representative. Similarly, Resident #81 was observed with bed rails up, although the annual MDS assessment also indicated that bed rails were not used. These observations were made on different days, confirming the inconsistency in the documentation and actual use of bed rails for both residents. Additionally, the facility failed to accurately document the discharge status of Resident #158. The medical record indicated that the resident was discharged to a short-term general hospital, while progress notes and physician orders confirmed that the resident was discharged home. This inconsistency was verified through an interview with a Licensed Practical Nurse (LPN) and Clinical Reimbursement Specialist (CRS). The facility's policies and procedures for discharge management and resident assessment were reviewed, highlighting the need for accurate documentation and coordination by the interdisciplinary team (IDT) and nursing staff.
Failure to Obtain Informed Consent and Properly Assess Bedrail Use
Penalty
Summary
The facility failed to ensure informed consent for the use of bedrails was obtained prior to their installation and did not properly assess residents for bedrail use. This deficiency was identified for three residents who had bedrails installed without documented informed consent or proper assessment. Resident #64, who had diagnoses including dementia and anxiety disorder, was observed with bedrails up, but there was no documentation of alternative methods tried or informed consent obtained. The resident's care plan and MDS assessment did not reflect the use of bedrails, and the resident's representative confirmed that they were not informed of the risks or asked to provide consent. Similarly, Resident #81, with diagnoses including psychosis and hemiplegia, was observed with bedrails up without any documentation of alternative methods or informed consent. The resident's care plan and MDS assessment did not address the use of bedrails, and the Occupational Therapy Plan of Care did not mention bedrails either. Staff interviews revealed uncertainty about the assessment process and the necessity of bedrails for this resident. Resident #311, who had multiple fractures and dementia, was also observed with bedrails up without proper assessment or informed consent. The resident's care plan and medical record did not document the use of bedrails or alternative methods tried. Staff interviews indicated that the bedrails were already installed when the resident was admitted, and there was no clear understanding of the assessment process for bedrail use. The facility's policy required thorough assessment and informed consent, which were not followed in these cases.
Failure to Provide Necessary Mobility Device
Penalty
Summary
The facility failed to accommodate the needs of Resident #39, who was diagnosed with Multiple Sclerosis (MS), obesity, and Lupus Erythematosus, by not providing a necessary mobility device. During an interview, Resident #39 expressed a desire to plan outings for the summer but stated that the facility had taken her wheelchair, leaving her without one. Observations confirmed that a wheelchair was not present in her room, despite her care plan indicating the need for a high back wheelchair due to her medical conditions. The care plan also specified the use of a wheelchair for locomotion and a total mechanical lift with two staff members for transferring. The resident's quarterly MDS assessment indicated she was cognitively intact and had used a wheelchair for mobility within the last seven days. Interviews with facility staff revealed inconsistencies and a lack of clarity regarding the provision of the wheelchair. The Occupational Therapist (OT) mentioned that residents are assessed for the type of chair they need but did not provide a clear reason why Resident #39 did not have a wheelchair. The Director of Nursing (DON) stated that assistive devices are provided based on therapy assessments and should remain with the resident for their entire stay, even if not used frequently. However, the DON could not explain why Resident #39 did not have a wheelchair available for her use, despite her documented need and the facility's policy.
Failure to Resolve Resident Grievance Regarding Missing Clothing
Penalty
Summary
The facility failed to resolve a resident grievance regarding missing clothing in a timely manner. Resident #143, who was admitted with a primary diagnosis of muscle wasting and atrophy and had intact cognition, reported missing clothes to the staff on multiple occasions. Despite the resident's repeated complaints and a detailed list of missing items, the facility did not locate the clothing or provide a satisfactory resolution. The resident expressed frustration over the ongoing issue and reluctance to send more clothes to the laundry due to fear of further losses. The grievance was officially filed on 04/29/24, and the facility's records indicated it was resolved by 05/08/24. However, the resident continued to report missing items and dissatisfaction with the facility's response. The facility offered items from the lost and found, which the resident declined, and there was a lack of clear communication regarding reimbursement or reordering of the missing items. The resident stated that the facility had not mentioned anything about helping him reorder the missing clothes. Interviews with staff, including the Unit Manager, Social Services Director, and Administrator, confirmed the resident's grievances and the facility's attempts to address the issue. However, the facility's efforts, including searching the laundry and lost and found, were unsuccessful, and the resident remained dissatisfied. The facility's grievance policy outlined the process for handling such concerns, but in this case, the resolution was not achieved to the resident's satisfaction.
Inaccurate PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of Level I Pre-Admission Screening and Resident Review (PASRR) assessments for three residents. Resident #24 was admitted with diagnoses including Alzheimer's disease, bipolar disorder, and schizoaffective disorder. The Level I PASRR form incorrectly indicated that the resident did not have a secondary diagnosis of dementia or Alzheimer's, and no request for a Level II PASRR evaluation was made. The Director of Nursing and the Social Service Director acknowledged the error, attributing it to confusion during the PASRR completion process with assistance from an outside vendor. Resident #81 was admitted with diagnoses including unspecified psychosis, dementia, anxiety disorder, depressive episodes, and insomnia. The Level I PASRR assessment did not trigger a Level II PASRR evaluation despite the presence of serious mental illness diagnoses. Similarly, Resident #38, who had major depressive disorder, bipolar disorder, vascular dementia, and schizoaffective disorder, had an incorrectly completed Level I PASRR form. The Social Services Director confirmed the error and submitted a Level II screening after the oversight was identified. The facility's PASRR policy mandates a Level II PASRR for residents with serious mental illness and dementia, which was not followed in these cases.
Failure to Update Care Plan After Discontinuation of Physician's Order
Penalty
Summary
The facility failed to review and revise the care plan for a resident who was admitted with multiple diagnoses, including hemiplegia, hemiparesis, and multiple sclerosis. The resident was observed without a foot brace, which was previously ordered but later discontinued. Despite the discontinuation of the physician's order for the foot brace, the care plan was not updated to reflect this change. The resident, who was cognitively intact, confirmed that she did not want to wear the shoe at the time of the interview. However, the care plan still included interventions related to the use of the foot brace, which was no longer applicable. Interviews with staff, including an LPN and the Director of Nursing (DON), revealed that the care plan should have been revised when the physician's order for the foot brace was discontinued. The facility's policy mandates that care plans be reviewed and revised periodically to reflect the resident's current health status. The failure to update the care plan resulted in outdated and irrelevant interventions being listed, which could potentially impact the resident's care and well-being.
Failure to Provide Nail Care
Penalty
Summary
The facility failed to provide necessary nail care for a resident who was unable to perform Activities of Daily Living (ADLs) independently. On 05/13/24, the resident expressed the need for her nails to be cut, stating that staff did not offer to cut her nails. On 05/15/24, the resident was observed with elongated, uneven, and jagged nails with visible dirt underneath. Despite the resident's request to a Certified Nursing Assistant (CNA) to cut her nails, the CNA stated she did not have a nail clipper and did not follow up on the resident's offer to use her own clippers. The resident's care plan indicated that she required assistance with personal hygiene, including nail care during bathing and as necessary, but this was not adhered to by the staff. Further investigation revealed that the CNAs were not responsible for cutting nails, as stated by the Director of Nursing (DON). Instead, the responsibility fell on the nurse or nurse manager. However, this protocol was not communicated effectively to the staff, leading to the resident's unmet need for nail care. The facility did not provide a policy related to nail care, indicating a lack of clear guidelines and procedures for staff to follow in such situations.
Failure to Ensure Communication with Hospice Providers
Penalty
Summary
The facility failed to ensure active and ongoing communication between the facility and hospice providers for two residents receiving hospice services. Resident #18, who has a history of malignant neoplasm of the lung, cognitive communication deficit, and other conditions, reported that hospice assists with her care. However, a review of her medical record revealed no hospice notes or communication forms. Staff interviews confirmed the absence of hospice documentation, and the Director of Nursing (DON) acknowledged that hospice notes should be part of the resident's medical record or placed in a hospice binder. The facility's Hospice Agreement mandates ongoing communication and documentation, which was not adhered to in this case. Resident #24, diagnosed with Alzheimer's Disease, reported severe pain levels of 10 during interviews. Despite having physician orders for multiple pain medications, the resident's pain was not adequately managed. Staff interviews revealed that the hospice nurse did not leave visit reports at the facility, and the Unit Manager was unaware of a hospice book. Additionally, a nurse was observed struggling to administer a Tylenol pill to the resident, who had difficulty swallowing. The DON stated that hospice staff should communicate with facility staff and leave visit notes, and that residents should be comfortable at all times with appropriate pain management. The lack of proper communication and documentation between the facility and hospice providers led to deficiencies in the care of both residents. The facility did not maintain hospice notes in the medical records, and there was inadequate pain management for Resident #24. These failures indicate a breach of the facility's Hospice Agreement and a lack of adherence to expected protocols for coordinating care with hospice services.
Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a medication administration error rate of 7.41%. During the observation of 27 medication administration opportunities, two errors were identified involving two residents. Resident #56 received an incorrect dose of folic acid, being administered 400 mcg instead of the prescribed 1 mg. Resident #4 was given Ferrous sulfate 325 mg instead of the prescribed Polysaccharide iron complex 150 mg. These errors were observed during medication administration by Staff K, RN, who did not verify the correct medications and dosages as per the physician's orders. Resident #56 was admitted with diagnoses of muscle wasting, atrophy, and polyosteoarthritis. The medication error for this resident involved the administration of folic acid at an incorrect dosage. Similarly, Resident #4, who was admitted with diagnoses of atrial fibrillation and cognitive communication deficit, received the wrong type of iron supplement. Staff K, RN, failed to follow the facility's policy of verifying the right dose, right medication, right route, right time, and right resident before administering the medications. The Director of Nursing (DON) confirmed that nursing staff are expected to verify the five rights of medication administration and compare the medication with the resident's medication administration record and physician's orders. The facility's policy on medication administration, effective since November 2018, mandates that medications be administered as prescribed and verified three times before administration. The failure to adhere to these procedures led to the identified medication errors.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
