Rehabilitation Center Of Winter Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Maitland, Florida.
- Location
- 1700 Monroe Ave, Maitland, Florida 32751
- CMS Provider Number
- 105430
- Inspections on file
- 31
- Latest survey
- January 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Rehabilitation Center Of Winter Park during CMS and state inspections, most recent first.
A resident under hospice care experienced a fall, and the LTC facility failed to notify the hospice provider of this change in condition. Despite the facility's policy requiring such notification, the hospice was informed by the resident's wife instead. Interviews with staff confirmed the lapse in communication, and the absence of documentation was validated by the interim DON.
The facility failed to maintain a homelike environment due to unresolved TV issues in multiple rooms, including fuzzy channels, limited availability, and malfunctioning remotes. Despite work orders being marked as completed, problems persisted, causing inconvenience to residents. The Maintenance Director acknowledged the deficiencies, highlighting a lack of effective follow-up and audits.
The facility failed to provide baseline care plan summaries to two residents or their representatives. One resident, admitted with multiple diagnoses including stroke and hemiplegia, had no baseline care plan in their EMR, and no documentation of review or signature. Another resident, admitted with a fall and dementia, also lacked a baseline care plan summary for the current admission, with only a previous admission's plan available. The DON confirmed the absence of proper documentation and was unsure of recent audits or education on care plans.
The facility failed to maintain complete and accurate medical records for two residents. One resident's Admission Agreement was missing, and there were discrepancies in the baseline care plan. Another resident's baseline care plan summary was missing from the electronic record. The DON confirmed the incomplete documentation, which did not adhere to the facility's policies on maintaining accurate records and ensuring residents' rights.
A facility failed to notify a resident's POA of significant changes in the resident's condition and treatment, including a skin tear, bruising, a coughing episode, a medication dosage change, and a rash. Despite the facility's policy requiring notification of the resident's legal representative, there was no documentation that the POA was informed in these instances.
Two residents with severe cognitive impairment experienced multiple injuries of unknown origin, which the facility failed to investigate or report as required by their policy. Despite family concerns and requests, the facility did not document the causes or conduct thorough investigations, nor did they assess other residents for similar injuries.
Two residents with cognitive impairments experienced multiple injuries of unknown origin, which the facility failed to report and investigate in a timely manner. The facility delayed reporting these injuries to the State agency and other entities, exceeding the 24-hour requirement. The facility's abuse policy requires immediate or 24-hour reporting, but this was not adhered to, resulting in a deficiency.
A resident with dementia experienced a delay in treatment due to the facility's failure to timely remove a foley catheter and collect a urine specimen. The catheter was not removed within the physician-ordered timeframe, and the urine sample was collected five days late, delaying the diagnosis and treatment of a urinary tract infection. The DON confirmed the delay in urine collection and catheter removal.
The facility failed to ensure accurate and complete PASARRs for three residents, leading to deficiencies in evaluating their mental health needs. One resident's PASARR did not reflect new diagnoses of anxiety and major depressive disorder, while another's incorrectly indicated no mental illness despite being on medications for delusional and psychotic disorders. A third resident's PASARR lacked updates for new diagnoses post-admission. Delays in correcting these issues were noted due to staff medical leave and ineffective planning.
The facility's QAPI committee failed to sustain prior improvement measures, leading to repeat deficiencies in assessment accuracy and tube feeding standards. Despite monthly meetings to review various areas, the facility was found noncompliant with the same issues cited in a previous survey, indicating insufficient auditing and oversight.
A resident with multiple medical conditions requiring assistance with meals was referred to as a "feeder" by CNAs, which was considered undignified and inappropriate by facility management. The facility's policy emphasizes treating residents with respect and dignity, yet the term persisted, indicating a failure to adhere to these standards.
A resident with mobility issues experienced unsanitary conditions in their room due to a bedside commode not being emptied for two days, resulting in a foul odor. Despite requests, staff failed to address the issue, with CNAs and an LPN involved. The facility's policy and job descriptions emphasize maintaining a clean environment, which was not upheld.
A resident with dysphagia and other conditions was inaccurately assessed in the MDS as needing partial/moderate assistance for eating, despite CNA documentation showing dependency on staff. The MDS Lead confirmed the error, highlighting a failure to ensure accurate assessments.
The facility failed to conduct required PASARR Level I and Level II evaluations for two residents with serious mental health conditions. One resident was admitted with psychosis and major depressive disorder, and another with severe dementia and bipolar disorder, but necessary evaluations were not completed prior to their admissions, as required by facility policy.
A facility failed to create a comprehensive care plan for a resident with diabetes, despite the resident's intact cognition and specific medication orders for diabetes management. The MDS Lead admitted that the care plan was missed due to the resident's frequent hospitalizations, contrary to the facility's policy requiring timely development of care plans based on assessment results.
A resident with severe cognitive impairment and multiple diagnoses was not provided appropriate tube feeding care. The feeding was administered at an incorrect rate and with delays, contrary to physician orders. Staff failed to verify the feeding rate, and the facility's policy on enteral feeding was not followed, as confirmed by the DON and RD.
A resident with end-stage renal disease received Diclofenac gel without proper dosing, as nursing staff failed to follow manufacturer's specifications. The medication was administered unmeasured, contrary to facility policy requiring specific dosage instructions. The DON and Consultant Pharmacist acknowledged the oversight, highlighting a lack of awareness among staff regarding correct dosing procedures.
Two residents were found without access to their call bells, which were out of reach, contrary to the facility's policy. Both residents had significant mobility limitations, requiring assistance for movement and transfers.
A resident with severe cognitive impairment and multiple health issues developed a sacral pressure ulcer, which was not treated promptly due to a delay in implementing the Wound Physician's orders. The facility failed to start the prescribed wound care treatment until three days after the ulcer was identified, resulting in a deficiency in care.
A resident left AMA due to the facility's failure to provide routine medications, while another resident received incorrect medication due to a nurse's error. The facility struggled with timely medication delivery and access to an automated dispensing cabinet, contributing to these deficiencies.
Failure to Notify Hospice Provider of Resident's Fall
Penalty
Summary
The facility failed to notify and update the hospice provider regarding a fall experienced by a resident who was under hospice care. The resident, admitted for respite care, had a medical history including dementia, neurocognitive disorder, depressive disorder, and insomnia. On the date of the incident, the resident was found on the floor next to his bed, and while the facility's Nurse Practitioner was notified, there was no documentation indicating that the hospice provider was informed of this change in condition. Interviews with facility staff, including a Registered Nurse and the interim Director of Nursing, confirmed that the facility's process required notifying the hospice service of any change in condition, such as a fall. However, the hospice provider was not informed by the facility; instead, the resident's wife reported the fall to the hospice service. The interim Director of Nursing validated the absence of documentation in the resident's medical record regarding the notification of the hospice service about the fall, which was a requirement as per the facility's policy.
Deficiencies in TV Functionality and Maintenance Services
Penalty
Summary
The facility failed to provide necessary maintenance services to ensure a comfortable, homelike environment for residents, as evidenced by issues with television functionality in multiple rooms. Residents reported problems such as fuzzy TV channels, limited channel availability, and malfunctioning remote controls. Despite work orders being marked as completed, observations confirmed that the issues persisted, indicating a lack of effective resolution. Residents expressed frustration over the unresolved TV issues, with some reporting that their concerns had been communicated to maintenance staff without satisfactory follow-up. In several instances, remote controls were found to operate multiple TVs in a room, causing inconvenience and disturbance to residents. Additionally, some TVs required frequent reprogramming, and there were instances where residents had to rely on antenna mode to receive clear channels. The Maintenance Director acknowledged the deficiencies, confirming that the TV issues were not homelike and that each resident should have their own functioning remote control. The facility's work order policy and resident rights policy emphasize the importance of maintaining a comfortable environment, yet the lack of audits and effective maintenance follow-up contributed to the ongoing deficiencies in TV functionality.
Failure to Provide Baseline Care Plan Summaries to Residents
Penalty
Summary
The facility failed to ensure that baseline care plan summaries were reviewed with or provided to residents and/or their representatives for two of the four residents reviewed. Resident #1 was admitted with multiple diagnoses, including cerebral infarction and hemiplegia, and resided in the facility for 10 days. Despite the initiation of a care plan upon admission, there was no baseline care plan present in the electronic medical record (EMR) for this resident, and no documentation indicated that the resident or their representative refused to review or sign the baseline care plan summary. The Director of Nursing (DON) confirmed the absence of a baseline care plan in the EMR and provided a paper copy that lacked a date of review or signature from the resident or representative. Resident #2, who was admitted with diagnoses such as a subsequent fall with fracture and dementia, also did not have a baseline care plan summary in their EMR for the current admission. The DON provided a copy of a baseline care plan summary dated from a previous admission, which did not include the signature page for review with the resident or representative. The DON acknowledged that nurses were responsible for the baseline care plans and was unsure if any audits or education had been conducted recently regarding care plans. The facility's policy stated that a written summary must be provided to the resident or representative by the completion of the comprehensive care plan.
Incomplete Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for two residents. For the first resident, admitted with multiple diagnoses including hypertension and diabetes, the Admission Agreement paperwork was missing, and there were discrepancies in the baseline care plan regarding discharge plans and signatures. The Director of Community Relations and the Admissions Director were unable to locate the signed admission agreement, and the Director of Nursing (DON) acknowledged the incomplete baseline care plan. Progress notes also conflicted with the baseline care plan's completion date, indicating a lack of proper documentation and record-keeping. For the second resident, who had a history of falls and other medical conditions, the baseline care plan summary was missing from the electronic record. The DON confirmed the absence of scanned documents for the baseline care plan and provided an incomplete paper copy missing critical information such as the completion date and signatures. The facility's policies emphasize the importance of maintaining accurate records and ensuring residents' rights, yet these were not adhered to, resulting in incomplete documentation for both residents.
Failure to Notify POA of Resident's Condition Changes
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) of changes in condition for one resident reviewed for change in condition. The resident, who had unspecified dementia with unspecified severity, was involved in multiple incidents where the POA was not informed. These incidents included a skin tear on the right forearm, bruises on the forehead and side of the left eye, a coughing episode that required a chest x-ray, a decrease in Trazadone dosage, and a rash treated with Permethrin External Liquid 1%. In each case, there was no documentation that the POA was notified, despite the facility's policy requiring notification of the resident's legal representative or an interested family member when there is a significant change in the resident's status or treatment. The Director of Nursing (DON) and the Assistant Administrator verified the lack of documentation for notifying the POA in each of these instances. The facility's change in condition policy and guidelines for abuse require that the resident's physician and legal representative be notified of significant changes in the resident's condition or treatment. However, the facility did not adhere to these policies, resulting in a deficiency in communication with the resident's POA regarding changes in the resident's health status and treatment.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to adhere to its policy and family requests to investigate injuries of unknown origin for two residents. Resident #1, who has unspecified dementia and severe cognitive impairment, experienced multiple injuries, including skin tears and bruises, over several months. The facility did not document the causes of these injuries, nor did they conduct investigations to determine their origins. Despite family concerns and requests for investigation, the facility did not report these injuries to the State Agency or other required entities. Resident #4, also with severe cognitive impairment, was observed with bruising on her hands and forearm. The facility attributed these injuries to blood draws but did not verify the number of attempts or conduct a thorough investigation. Later, the resident's family raised concerns about potential abuse by a CNA, leading to the CNA's suspension. However, the facility did not assess other residents with similar cognitive impairments for unexplained injuries, nor did they report the incident to the State Agency. The facility's policy, dated April 2022, mandates prompt and thorough investigations of abuse and injuries of unknown origin. Despite this, the facility did not follow its guidelines, failing to investigate or report the injuries of the two residents, which could potentially indicate neglect or abuse.
Failure to Timely Report and Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin in a timely manner for two residents, leading to a deficiency. Resident #4, who had severe cognitive impairment, was found with multiple bruises on her hands and arms. The facility delayed reporting these injuries to the State agency and other entities, exceeding the 24-hour requirement. The Assistant Administrator confirmed the delay and acknowledged that the facility did not conduct a thorough investigation to determine the cause of the bruises, nor did they notify the appropriate authorities. Resident #1, who had unspecified dementia, experienced multiple injuries, including a skin tear on the right forearm, bruises on the forehead and side of the left eye, and a skin tear on the right elbow and lower leg. The facility did not document the causes of these injuries or conduct investigations to determine their origins. Additionally, the facility failed to report these injuries to the State agency or other required entities, as confirmed by the Administrator and Assistant Administrator. The facility's abuse policy requires that injuries of unknown origin be reported immediately or within 24 hours, depending on the severity. However, the facility did not adhere to this policy, as evidenced by the lack of timely reporting and investigation of the injuries sustained by Residents #1 and #4. The facility's failure to follow its own policy and regulatory requirements resulted in a deficiency being identified during the survey.
Delay in Urine Collection and Catheter Removal
Penalty
Summary
The facility failed to timely remove an indwelling urinary catheter and collect a urine specimen for a resident, leading to a delay in treatment. The resident, who had unspecified dementia and was unable to communicate effectively, was initially straight catheterized due to no urine output. A physician ordered a urinalysis with culture and sensitivity and the placement of a foley catheter for three days. However, the catheter was not removed within the specified timeframe, and the urine sample was not collected until five days after the catheter was inserted. The Treatment Administration Record (TAR) lacked instructions for the catheter's removal after three days, and there were missing patency checks on two shifts. Despite documentation indicating the catheter was removed on a specific date, nurses continued to document patency checks afterward. The urinalysis was collected six days after the initial order, and the results were reported two days later, delaying the diagnosis and treatment of a urinary tract infection by nine days. The Director of Nursing acknowledged the delay in urine collection and catheter removal, confirming the delay in treatment.
Deficiencies in PASARR Completion and Accuracy
Penalty
Summary
The facility failed to ensure the completion and accuracy of Level I Preadmission Screening and Resident Reviews (PASARRs) for three residents, leading to deficiencies in the evaluation of their mental health needs. Resident #90 was admitted with diagnoses including bipolar disorder, anxiety, and major depressive disorder, but her PASARR did not reflect the anxiety and major depressive disorder diagnoses. The Social Service Director and the Director of Nursing (DON) acknowledged that a new Level I PASARR should have been submitted following the new diagnoses, but it was not completed. Resident #134 was admitted with multiple diagnoses, including delusional and psychotic disorders, but his PASARR form incorrectly indicated no mental illness. Despite being on medications for these conditions, the PASARR was not updated to reflect his mental health diagnoses. The oversight in updating the PASARR form resulted in a lack of appropriate mental health evaluations and referrals. Resident #22 was admitted with dementia and anxiety, later diagnosed with psychotic disorder and major depression. Her PASARR did not indicate any mental health diagnoses, and no updates were made post-admission. The Social Service Director acknowledged the inaccuracies and initiated an audit to correct PASARRs, but the process was delayed due to her medical leave. The Regional Nurse Consultant noted the delay and the ineffectiveness of the Performance Improvement Plan (PIP) due to a lack of target dates and task delegation.
Repeat Deficiencies in QAPI Committee's Performance Improvement Activities
Penalty
Summary
The facility failed to ensure that its Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted effective performance improvement activities to sustain prior improvement measures. The facility had previously been cited for deficiencies at F641 for the accuracy of assessments and F693 for concerns with tube feeding per physician orders and standards of care during a recertification survey conducted in October 2022. During the current survey, the facility was found to be in noncompliance with the same deficiencies, indicating insufficient auditing and oversight to prevent these repeat citations. The Administrator acknowledged the repeat citations and stated that the process failed, despite the QAPI committee meeting monthly to review various areas, including reportable incidents, clinical metrics, care issues, grievances, and survey activity.
Failure to Maintain Resident Dignity in Meal Assistance
Penalty
Summary
The facility failed to treat a resident requiring assistance with meals in a dignified and respectful manner. The resident, who was readmitted with diagnoses including dysphagia, aphasia, stroke, and contracture of the right hand, was dependent on staff for most activities of daily living, including eating. During interviews, several CNAs referred to the resident as a "feeder," a term deemed inappropriate and undignified by the facility's management. The Keys Unit Manager and the Director of Nursing both stated that residents requiring assistance with meals should be referred to as "dependent diners" instead of "feeders," highlighting the importance of maintaining resident dignity. The Resident Council President also noted that the term "feeder" had been used by CNAs in the past and had been brought to staff attention as demeaning and demoralizing. The facility's policy on Resident Rights emphasizes treating each resident with respect and dignity, and the CNA job description requires care to be provided in a manner that protects and promotes resident rights and dignity. Despite these policies, the use of the term "feeder" persisted, indicating a failure to adhere to the facility's standards for respectful communication and resident dignity.
Failure to Maintain Sanitary Environment for Resident
Penalty
Summary
The facility failed to provide a sanitary, comfortable, and homelike environment for a resident who was admitted with diagnoses including a left leg above the knee amputation and required assistance with personal care. The resident was observed in his room with a bedside commode that had not been emptied for two days, resulting in a foul odor and the presence of feces and urine. Despite the resident's request to staff during breakfast service to empty the commode, he was informed that it was not their responsibility. Subsequent observations confirmed that the commode remained unemptied, and the odor persisted in the room. Certified Nursing Assistants (CNAs) and a Licensed Practical Nurse (LPN) were involved in the situation. CNA B claimed she was not asked to empty the commode and believed the resident used the bathroom instead. CNA A, who was present the following day, acknowledged the odor but assumed it was due to the resident soiling himself. LPN D was aware of the issue and had instructed CNAs to empty the commode, but it remained unaddressed. The Director of Nursing confirmed that it was the responsibility of any staff to check and empty commodes, and the facility's job description for CNAs included maintaining a clean environment. The facility's policy emphasized providing a safe, clean, and comfortable environment, which was not upheld in this instance.
Inaccurate MDS Assessment for Eating Assistance
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for a resident with significant medical conditions, including dysphagia, aphasia, stroke, and contracture of the right hand. The resident was observed to require extensive assistance for eating, as documented by Certified Nursing Assistants (CNAs) who reported the resident was dependent on staff for eating on multiple occasions. However, the MDS assessments inaccurately recorded the resident as needing only partial/moderate assistance for eating, which was inconsistent with the care plan and CNA documentation. The MDS Lead confirmed that the assessments for March and June 2024 incorrectly showed the resident required partial/moderate assistance, despite evidence indicating the resident was dependent on staff for eating. The MDS Lead acknowledged the importance of accurate MDS assessments for proper resident care and mentioned that any incorrect coding would require revision. The facility's policy emphasized the need for comprehensive and accurate assessments, but the discrepancy in the MDS coding suggests a failure to adhere to these guidelines.
Failure to Conduct Required PASARR Evaluations
Penalty
Summary
The facility failed to request Preadmission Screening and Resident Review (PASARR) Level I and Level II evaluations for two residents, leading to a deficiency. Resident #100 was admitted with diagnoses of psychosis and major depressive disorder, and her medical records indicated severely impaired cognitive skills. A Level I PASARR conducted prior to her admission triggered the need for a Level II evaluation due to a serious mental illness diagnosis. However, the Social Service Director could not locate the Level II PASARR, and it was confirmed that it was not submitted prior to admission, as required. Similarly, Resident #93 was admitted with severe dementia, bipolar disorder, and other mental health conditions. The Social Service Director and the Director of Nursing (DON) were unable to confirm if a Level I PASARR was submitted before his admission, despite the requirement for such a submission. The facility's policy mandates that all residents receive a PASARR in accordance with state and federal regulations, but this was not adhered to in these cases, resulting in a deficiency.
Failure to Develop Comprehensive Care Plan for Diabetic Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with diabetes, which was identified during a review of the resident's medical records. The resident, who was readmitted to the facility with diagnoses of type 2 diabetes mellitus, lupus, and congestive heart failure, had an intact cognitive status as indicated by a Brief Interview for Mental Status score of 15 out of 15. Despite receiving insulin injections and having specific medication orders for diabetes management, a comprehensive care plan addressing these needs was not developed following the completion of the admission Minimum Data Set (MDS) assessment. The MDS Lead, responsible for overseeing MDS assessments and care plan development, acknowledged that a full care plan should have been completed when the admission MDS assessment was finalized. However, due to the resident's frequent hospitalizations since admission, the care plan was overlooked and not developed until later. The facility's policy stated that assessment results should be used to develop, review, and revise the resident's comprehensive care plan, but this was not adhered to in this case.
Failure to Adhere to Tube Feeding Orders
Penalty
Summary
The facility failed to provide appropriate care for a resident on tube feedings, specifically in relation to the feeding rate and timing. Resident #48, who was severely cognitively impaired and dependent on staff for all care, was readmitted to the facility with multiple diagnoses including metabolic encephalopathy, diabetes mellitus type II, and dysphagia. The resident had an order for Glucerna 1.2 kcal to be administered via PEG tube at a continuous rate of 75 ml/hr for 20 hours, with a scheduled break from 10:00 AM to 2:00 PM. On multiple occasions, the feeding was not administered according to the physician's orders. On one instance, the feeding was stopped later than scheduled due to staff being busy, and the restart was delayed by more than two hours. Additionally, the feeding pump was running at a rate of 60 ml/hr instead of the ordered 75 ml/hr. The LPN responsible for the resident's care acknowledged the discrepancy and admitted to not verifying the rate on the feeding pump, as she was not the original nurse who set it up. The facility's policy required nurses to follow physician orders for enteral feedings, including verifying the rate and documenting any delays. The Director of Nursing confirmed that all nurses received competencies on tube feeding upon hire, and any delays should be documented with the physician notified. The Registered Dietitian highlighted that incorrect feeding rates could lead to unintentional weight loss and poor wound healing, emphasizing the importance of adhering to physician orders.
Improper Administration of Diclofenac Gel
Penalty
Summary
The facility failed to ensure the proper preparation and administration of Diclofenac Sodium External Gel, an over-the-counter medication, for a resident undergoing dialysis. The resident, who had multiple diagnoses including end-stage renal disease and was dependent on renal dialysis, was prescribed Diclofenac gel for pain relief. However, the nursing staff did not follow the manufacturer's specifications for dosing, which required the use of a dosing card to measure the correct amount in grams. Instead, the nurses administered the medication by squeezing an unmeasured amount into a medication cup, unaware of the specific dosing instructions. Interviews with the nursing staff revealed a lack of awareness regarding the need to measure the medication dose accurately. The Director of Nursing acknowledged that the order should have specified a dose, and the Consultant Pharmacist noted that a clarification process should have been initiated to ensure the correct dosage was administered. The facility's policy required medication orders to include specific dosage and frequency, which was not adhered to in this case, potentially putting the resident at risk due to their compromised renal function.
Deficiency in Call Bell Accessibility for Residents
Penalty
Summary
The facility failed to ensure that residents had access to a functioning call bell system, as observed in the cases of two residents. During an observation, both residents were found in their shared room without access to their call bells, which were attached to the wall behind their beds and out of reach. When asked, one resident indicated that he did not have a call bell, and his roommate confirmed the same. A registered nurse verified the situation and acknowledged that the call bells should have been within reach of the residents. The medical records of the two residents revealed significant mobility limitations. One resident was dependent on staff for movement and required a two-person assist with a mechanical lift for transfers, while the other needed supervision to roll side to side and a minimum assist of one person for transfers. The facility's call bell policy mandates that all residents must have access to call bells at all times, regardless of their ability to use them, and staff are expected to ensure the call bell is within reach while residents are in bed.
Delayed Wound Care for Pressure Ulcer
Penalty
Summary
The facility failed to provide appropriate care and treatment for a sacral pressure ulcer for a resident, leading to a deficiency in care. The resident, who was readmitted with multiple diagnoses including dysphagia, end-stage renal disease, and severe cognitive impairment, was initially assessed as being at risk for pressure ulcers but did not have any at the time of the assessment. However, a subsequent observation on August 23 revealed an open area on the resident's buttocks, which was later identified as a sacral pressure ulcer by a Wound Physician. The ulcer was described as having necrotic adipose tissue exposed and required specific wound care treatment. Despite the Wound Physician's consultation and orders on August 23, the facility did not commence the prescribed wound treatment until August 27, three days later. The Unit Manager admitted to assuming that the Wound Care Nurse, who had recently resigned, would handle the wound care orders. The delay in treatment was attributed to a lack of communication and documentation, as the Wound Care Physician's orders were not entered or started until days after the consultation. This oversight resulted in the resident not receiving the necessary wound care for several days, which was acknowledged by the Unit Manager.
Medication Administration Failures Lead to Resident Leaving AMA and Medication Error
Penalty
Summary
The facility failed to ensure the availability of routine medications for a newly admitted resident, leading to the resident leaving the facility Against Medical Advice (AMA). The resident, who was cognitively intact, was admitted with multiple diagnoses including cellulitis, acute respiratory failure, and pneumonia. Despite having 12 routine medications ordered, the resident did not receive 8 of these medications during her stay. The facility staff informed her that they were working on obtaining the medications from the pharmacy, but the delay led the resident to bring her own medications from home. When the facility did not allow her to keep her home medications at the bedside, she decided to leave AMA. The facility also failed to administer medications as ordered to another resident, resulting in the resident receiving incorrect medication. This resident, who had mild cognitive impairment, was given Vitamin C instead of the prescribed Vitamin D. The error occurred when a nurse, who was not the resident's usual caregiver, administered the medication. The facility's policy required verification of the right medication before administration, but this protocol was not followed, leading to the medication error. Interviews with facility staff revealed issues with the medication delivery process, including delays in receiving medications from the pharmacy and limited access to the automated medication dispensing cabinet. The Director of Nursing (DON) and other staff members acknowledged the challenges in obtaining medications promptly, especially for newly admitted residents. There was no documentation explaining why the medications were not available, and the facility's process for handling home medications was not effectively communicated to the resident.
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.
