Sarasota Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sarasota, Florida.
- Location
- 1524 East Avenue South, Sarasota, Florida 34239
- CMS Provider Number
- 105155
- Inspections on file
- 19
- Latest survey
- November 12, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Sarasota Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was readmitted after hospital treatment for scabies, but the facility did not document required skin assessments for the resident, close contacts, or staff, nor did it clean or launder clothing, bedding, or the room as per policy. No staff in-services on scabies were conducted, resulting in noncompliance with infection control protocols.
A resident with severe cognitive impairment and physical dependency was found with a significant bruise and later diagnosed with a femoral neck fracture. The facility did not document a thorough investigation, as required by policy, with missing staff statements and unwitnessed accounts of the incident. Interviews revealed that the DON and other staff could not provide written documentation or clear details about how the injury occurred.
The facility did not have effective supervision processes for cognitively impaired residents with aggressive behaviors, resulting in multiple incidents where residents physically assaulted each other, causing injuries such as scratches and skin tears. Staff were not present or did not intervene during these altercations, and existing monitoring programs were insufficient to prevent these events.
Multiple residents with cognitive impairment and aggressive behaviors were involved in repeated physical altercations, including hitting and scratching, resulting in injuries. These incidents occurred in various areas of the secured dementia unit without adequate staff supervision or individualized care plan interventions. Staff were often unaware of residents' whereabouts, and behavioral monitoring was insufficient, leading to a pattern of harm and risk among residents.
A facility failed to ensure a dietary aide was screened for a history of abuse, neglect, or exploitation before employment. Despite a policy requiring background checks, the aide was not entered into the Florida Agency For Healthcare Administration's Care Provider Background Screening Clearinghouse, and a new screening was not obtained after a break in employment. The aide worked several days without the required screening, violating state regulations and facility policies.
A resident with severe cognitive impairment was administered psychotropic medications without informed consent from the appointed health care surrogate (HCS). The facility failed to inform the HCS about the risks, benefits, side effects, and alternatives of the medications. Interviews and record reviews confirmed the absence of signed consent forms and documentation of discussions with the HCS.
A resident with severe cognitive impairment and multiple medical conditions experienced an injury of unknown origin. The facility failed to thoroughly investigate the incident, as the investigation did not consider the possibility that the right arm fracture occurred when a left arm injury was documented. The investigation lacked staff statements and an interview with the LPN who noted the initial injury. The facility's failure to conduct a thorough investigation was acknowledged by the current Administrator and Interim DON.
A facility failed to provide adequate social services for a resident with toxic encephalopathy and dementia, who wished to relocate closer to family. Despite the family's request for assistance, the social worker did not actively help in finding a suitable facility, leaving the family to independently search for a specialized dementia care unit. The Nursing Home Administrator acknowledged that the social services director should assist in such situations.
A facility failed to maintain proper communication and documentation for a resident receiving dialysis. The required Dialysis Communication Tool forms were missing or incomplete for several dates, lacking necessary information, signatures, and timestamps. This deficiency was confirmed by staff, highlighting a failure to adhere to the facility's policy, which could impact the resident's care and safety.
The facility failed to provide necessary dental services for four residents, resulting in unmet dental needs. A resident was edentulous and had not received dentures or seen a dentist since admission. Another resident had multiple missing and broken teeth but did not receive dental care. A third resident had broken teeth, and their care plan did not address the issue. Lastly, a resident with loose dentures experienced weight loss, and the facility staff were unaware of the problem.
A facility licensed for 169 beds failed to ensure their full-time social worker met the required qualifications. The current social worker, who started in March 2024, only held a bachelor's degree in social work and lacked the necessary one year of supervised experience in a healthcare setting. Additionally, there was no signed job description on file. The Regional Consultant confirmed the absence of a qualified regional social worker to fill in until a qualified hire is made.
A facility failed to obtain a valid Do Not Resuscitate Order (DNRO) for a resident with severe cognitive impairment. The resident's sister signed a DNR form, but it was not signed by a physician and not available in the clinical record. Staff interviews revealed confusion about the DNR's validity without the signed form, leading to potential CPR administration despite DNR orders.
A resident with multiple missing and broken teeth was inaccurately assessed in the MDS as having intact natural teeth. Despite informing staff of her dental issues and desire for dentures, the MDS and Nursing Admission Data Collection forms were incorrectly coded, failing to reflect her true dental status. This discrepancy was confirmed by the SSD and MDS Coordinator after reviewing the resident's medical record and conducting interviews.
Two residents with cognitive impairments and functional limitations did not receive necessary grooming and nail care assistance as per their care plans. Despite being dependent on staff for personal hygiene, both residents were observed with long fingernails and facial hair growth. Staff acknowledged the need for grooming but failed to provide consistent care, revealing a deficiency in meeting the personal care needs of these residents.
The facility failed to ensure that two residents participated in activities of their choice, impacting their psychosocial well-being. Observations showed the residents were often in their rooms without engaging in activities, despite care plans indicating preferences for afternoon activities. The DOA assumed staff would facilitate activities without verifying participation, leading to a deficiency in activity provision.
A resident with impaired vision due to glaucoma was not provided timely assistance in replacing lost prescription glasses. Despite multiple observations of the resident without glasses and her reports of the loss, the facility's Social Services department did not take action to address the issue. The resident's care plan included interventions for glasses maintenance, but there was no documented follow-up or grievance filed. The Social Service Director was unaware of the missing glasses, highlighting a communication lapse within the facility.
A resident with impaired cognition and range of motion did not receive proper care to prevent contractures. Despite a care plan requiring splints, the resident was often observed without them, and staff failed to document any refusal. Interviews revealed confusion about responsibilities, and therapy records did not address the resident's needs. The DON could not provide relevant documentation.
The facility did not post the required daily nurse staffing information, as observed over three days. The Administrator admitted that the facility had not posted this information since late February, acknowledging the requirement to display it prominently.
Failure to Implement and Document Infection Control Measures for Scabies
Penalty
Summary
The facility failed to follow its infection prevention and control procedures to prevent the potential spread of scabies in the Memory Care Unit. According to the facility's policy, early identification and management of scabies, including treatment of close contacts, laundering of clothing and bedding, and thorough cleaning of the resident's environment, are required. However, after a resident was diagnosed and treated for scabies at the hospital and subsequently readmitted, the Infection Preventionist (IP) did not document the skin assessments performed on the resident, the roommate, or other close contacts. Additionally, the IP did not document inquiries made to staff regarding rashes or skin issues. The facility did not clean or launder the resident's or roommate's clothing, bedding, or room prior to the resident's return from the hospital, as required by policy. The resident involved had severe cognitive impairment and was dependent on staff for all activities of daily living. The IP acknowledged that no in-services were conducted for staff regarding scabies management, as it was deemed unnecessary. The lack of documentation and failure to implement required infection control measures, including environmental cleaning and staff education, contributed to the facility's noncompliance with its own infection prevention and control program.
Failure to Document Thorough Investigation of Injury of Unknown Origin
Penalty
Summary
The facility failed to document a thorough investigation into an injury of unknown origin for one resident with significant cognitive impairment and physical dependency. The resident, who had diagnoses including a displaced femoral neck fracture, dementia, and anxiety disorder, was found with a bruise on the right medial knee/shin. The initial nursing note indicated the bruise was noticed in the dining room, but the event was unwitnessed, and the resident was unable to describe what happened. The facility's incident investigation form noted the injury was not witnessed, and immediate actions included ordering an X-ray and considering changes to table height. However, there was no documentation of staff or resident statements, and the investigation lacked written accounts from those involved or present at the time. Interviews with the DON and staff revealed inconsistencies and gaps in the investigation process. The DON stated that no one witnessed the incident and that he could not locate statements from the nurse or CNA, with the Unit Manager only verbally asking staff about the event without documentation. A CNA reported discovering the bruise during rounds and notifying the nurse, but did not witness the resident hitting her leg. The LPN recalled being informed of the bruise and assessing it, but also did not witness the event and stated that assumptions could not be made. The lack of documented interviews, statements, and a comprehensive investigation process led to the deficiency cited in the report.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect residents' right to be free from abuse by not having effective processes in place to supervise cognitively impaired residents with known aggressive behaviors. Multiple incidents occurred in which residents with histories of aggression, wandering, or agitation were not adequately supervised, resulting in avoidable resident-to-resident altercations. These altercations led to physical injuries, including scratches and skin tears, among several residents. Specific events included residents hitting, scratching, or otherwise physically assaulting each other in various locations such as hallways, activity rooms, and dining areas. In several instances, residents with dementia or behavioral disturbances wandered unsupervised into other residents' rooms, leading to confrontations and injuries. Staff were observed not supervising residents at critical times, and altercations occurred without immediate staff intervention. The facility's monitoring program, which involved staff rounding every 15 minutes, was not sufficient to prevent these incidents. The facility's own records and staff interviews confirmed that incidents of resident-to-resident aggression continued to occur despite the implementation of monitoring programs. The Director of Nursing acknowledged the high frequency of such altercations, and the Administrator verified multiple incidents of physical abuse between residents. The lack of adequate supervision and ineffective monitoring processes directly resulted in physical harm to several residents and led to a determination of Immediate Jeopardy.
Removal Plan
- The Risk Consultant educated the Administrator and Director of Nursing on abuse, neglect, and exploitation as well as the reporting requirements to the Facility Risk Manager, Nursing Home Administrator, or direct supervisor as they relate to ensuring adequate supervision to ensure the safety of cognitively impaired residents on the secured dementia unit to prevent further incidents of resident-to-resident physical altercations and abuse.
- Administrator educated staff on abuse, neglect, and exploitation as well as the reporting requirements to the Facility Risk Manager, Nursing Home Administrator, or direct supervisor. 147 out of 147 staff members were educated.
- Administrator educated staff on abuse, neglect, and exploitation as they relate to ensuring adequate supervision to ensure the safety of cognitively impaired residents on the secured dementia unit to prevent further incidents of resident-to-resident physical altercations and abuse. 147 out of 147 staff members were trained.
- A Quality Assurance and Assessment meeting was held. Psychiatric services attended with the facility interdisciplinary team and reviewed high risk residents with behaviors. Medications and care planned interventions for behaviors were reviewed.
- Psychiatric service visits were increased for high-risk residents.
- Facility leadership along with the interdisciplinary team planned for enhanced oversight of the secured unit to monitor hallways and common areas for negative behaviors that could lead to a resident-to-resident altercation. Enhanced oversight was initiated.
- Two staff were assigned per shift to conduct enhanced oversight.
- The Administrator or designee is responsible for ensuring that enhanced oversight of the secured unit is in place.
- A qualified activity staff member was assigned to activities in the secured unit.
- A Quality Assurance meeting was conducted to review the effectiveness of the implemented interventions.
Failure to Prevent Resident-to-Resident Altercations Due to Inadequate Supervision
Penalty
Summary
The facility failed to implement adequate supervision and processes on the secured dementia unit to prevent multiple avoidable incidents of resident-to-resident physical altercations among cognitively impaired residents with aggressive behaviors. Over a period of several weeks, numerous residents with severe to moderate cognitive impairment and behavioral disturbances were involved in repeated physical altercations, including hitting, scratching, and grabbing, resulting in injuries such as skin tears, scratches, and emotional distress. These incidents occurred in various locations within the secured unit, including hallways, resident rooms, the dining room, and the activity room, often without staff present to intervene or prevent escalation. Care plans for residents with known aggressive behaviors and wandering tendencies were found to be insufficiently individualized and did not consistently include interventions to ensure adequate supervision or to protect other residents from harm. In several cases, residents with a history of aggression or wandering were not monitored closely enough, leading to altercations when they entered other residents' rooms or were in close proximity to others. Documentation revealed that staff were sometimes unaware of residents' whereabouts or did not witness the altercations, and in some cases, staff only became aware of incidents after hearing raised voices or residents calling for help. Behavioral monitoring and documentation of target behaviors for psychotropic medication use were also lacking or incomplete. The facility's failure to provide necessary structures and supervision resulted in physical injuries to several residents and created a likelihood of serious harm to others. The pattern of incidents demonstrated a lack of effective oversight and intervention for residents at high risk for aggressive behaviors, despite their known diagnoses of dementia, mood disorders, and behavioral disturbances. The deficiency was determined to be at the Immediate Jeopardy level due to the ongoing risk and actual harm experienced by residents on the secured dementia unit.
Removal Plan
- Educate the Administrator and Director of Nursing on ensuring that residents on the secured dementia unit are provided with adequate supervision to prevent incidents of resident-to-resident physical altercations and ensure resident safety.
- Educate staff on ensuring that residents on the secured dementia unit are provided with adequate supervision to prevent incidents of resident-to-resident physical altercations and ensure resident safety.
- Give specific examples of behavioral patterns that potentially lead to resident-to-resident altercations such as wandering patterns and behaviors, proximity of residents, verbal queues, and physical queues.
- Initiate enhanced monitoring and oversight by facility leadership over the secured unit to monitor patient care areas and resident rooms for resident behaviors that could lead to resident-to-resident altercations.
- Ensure that enhanced oversight of the secured unit is in place.
Failure to Screen Employee for Abuse History
Penalty
Summary
The facility failed to protect the health, welfare, and rights of its residents by not ensuring that a dietary aide, referred to as Staff A, was properly screened for a history of abuse, neglect, exploitation, or misappropriation of resident property before beginning employment. The facility's Abuse Prevention Program, which was last updated in November 2024, mandates that potential employees undergo criminal background checks as part of the hiring process to identify any history of abuse or mistreatment. However, Staff A, who was hired on January 14, 2025, was not entered into the Florida Agency For Healthcare Administration's Care Provider Background Screening Clearinghouse, and a new background screening was not obtained despite a break in employment greater than 90 days. The Human Resources Director confirmed that Staff A's employment was not recorded in the background screening clearinghouse, and the last eligibility determination for employment at a Medicaid/Medicare Participating Provider was dated March 23, 2023. Despite this oversight, Staff A worked multiple days in February 2025 without the required screening, which is a violation of the facility's policies and state regulations. This failure to conduct the necessary background checks before employment poses a risk to the residents' safety and well-being.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to honor the right of a resident's health care surrogate (HCS) to be informed about the risks, benefits, side effects, and alternatives of psychotropic medications administered to the resident. The resident, who had severe cognitive impairment and was diagnosed with non-Alzheimer's dementia, was deemed incapable of making informed medical decisions. Consequently, the resident's son was appointed as the HCS. Despite this, the facility administered several psychotropic medications, including Buspirone, Seroquel, Trazodone, and Depakote, without obtaining informed consent from the HCS. Interviews and record reviews revealed that the facility did not have signed consent forms for these medications, and the HCS was not informed about the medications' risks, benefits, side effects, or alternatives. The HCS explicitly stated that he did not consent to the use of antipsychotics and was not informed by the facility staff, who primarily communicated with the business office manager. The psychiatric specialist assumed that the facility obtained the necessary consents but could not recall discussing the medications with the HCS. The medical records lacked documentation of any informed consent discussions with the HCS.
Inadequate Investigation of Resident's Injury
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident with severe cognitive impairment and multiple medical conditions, including dementia and hemiplegia. The resident was dependent on staff for personal care and mobility. On June 20, 2024, staff noted the resident favoring her left arm and screaming when it was touched, leading to an X-ray that showed no fracture. However, on June 23, 2024, the resident complained of pain in her right forearm, which was swollen and discolored. The resident was sent to the emergency room, where a fracture of the right ulna was identified, and the physician noted the bruising appeared old. The facility's investigation into the injury was inadequate, as it did not consider the possibility that the right arm injury occurred on June 20, 2024, when the left arm injury was documented. The investigation lacked documentation of any trauma to the left arm after June 20, 2024, and did not include written statements from staff or an interview with the LPN who initially documented the left arm injury. The facility's failure to conduct a thorough investigation was acknowledged by the current Administrator and Interim Director of Nursing.
Failure to Assist in Resident Relocation
Penalty
Summary
The facility failed to provide adequate social services for the discharge and transfer of a resident diagnosed with toxic encephalopathy and dementia. The resident and their family expressed a desire to relocate the resident to a skilled nursing facility closer to family. The social worker's care plan included assisting with referrals to facilities in the desired area and facilitating a safe discharge. However, the social worker did not actively assist the family in finding a suitable facility, despite the family's request for help and the resident's need for a specialized dementia care unit. The Health Care Surrogate (HCS) for the resident reported that the facility instructed them to find a suitable facility independently, with the facility only offering to fax referrals once a location was identified. The Nursing Home Administrator, who had recently started at the facility, stated that the social services director should assist families in such situations. Despite this, the social worker did not provide the necessary support, resulting in the resident remaining in the facility without the desired relocation closer to family.
Failure in Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure proper communication and documentation between the nursing facility and the dialysis center for a resident receiving dialysis. The facility's policy required the completion of a Dialysis Communication Tool before and after each dialysis session to maintain communication and ensure the resident's stability. However, the review of the resident's records revealed missing forms for several dates and incomplete forms lacking required information, signatures, dates, and times. This deficiency was confirmed by both a registered nurse and a unit manager, who acknowledged the missing and incomplete documentation. The resident involved had multiple diagnoses, including anemia, end-stage renal disease, and heart failure, and was scheduled for dialysis three times a week. Despite the critical nature of the resident's condition, the facility did not adhere to its policy, resulting in a lack of documented communication and assessment of the resident's condition before and after dialysis treatments. This oversight in documentation and communication could potentially impact the resident's care and safety.
Failure to Provide Dental Services for Residents
Penalty
Summary
The facility failed to provide or obtain necessary dental services for four residents, leading to unmet dental needs. Resident #45, who was edentulous, had not received dentures or seen a dentist since admission, despite expressing a desire for dentures. The facility's staff, including nurses and social services, did not follow up on the initial referral for dental services, and there was no documentation of any dental appointments or evaluations in the resident's clinical record. Resident #25 had multiple missing and broken teeth upon admission and expressed a desire to have her remaining teeth extracted for dentures. However, the facility did not arrange for dental services, and the nursing assessment failed to document her dental issues. The resident's requests for dental care were not addressed, and no appointments were scheduled to evaluate or treat her dental concerns. Resident #94 was observed with broken front upper teeth, but her care plan did not reflect her dental status or provide interventions for her dental issues. Similarly, Resident #44 had loose upper dentures that were not addressed by the facility, contributing to his weight loss and insufficient food intake. The facility's staff, including the Registered Dietitian and Social Service Director, were unaware of the resident's dental problems, and no actions were taken to address the loose dentures.
Unqualified Social Worker in Facility
Penalty
Summary
The facility, licensed for 169 beds, failed to ensure that the full-time social worker met the required qualifications. The facility's policy and procedure, effective February 2021, stated that social services staff should have qualifications in line with state and federal regulations, job responsibilities, and applicable licensure laws. However, the current full-time social worker, who assumed the role in March 2024, only held a bachelor's degree in social work and lacked the required one year of supervised social work experience in a healthcare setting. Additionally, there was no signed job description on file for the current social worker. The Regional Consultant confirmed that the previous social worker left in March and that there was no qualified regional social worker available to fill in until a qualified social worker was hired.
Failure to Obtain Valid DNR Order
Penalty
Summary
The facility failed to obtain a Do Not Resuscitate Order (DNRO) in accordance with the advanced directives for a resident with severe cognitive impairment. The resident, who had been diagnosed with anxiety disorder and Parkinson's disease, had a designated durable power of attorney, which did not include health care decisions. Despite the physician issuing a DNR order, the clinical record lacked documentation that the resident had verbalized the wish not to receive CPR in the event of cardiac or respiratory arrest. Additionally, there was no incapacity statement authorizing the resident's sister to make health care decisions on his behalf. The facility's policy required that if a resident or their representative verbalizes the wish not to receive CPR, two staff members must witness and document this request, and the conversation should be printed and placed as the first document in the medical record. However, the yellow Florida DNR form signed by the resident's sister was not signed by the physician and was not available in the clinical record for staff reference. Interviews with staff revealed confusion about the validity of the DNR order without the signed yellow form, indicating that CPR would be performed if the form was not present, even if the computer and orders indicated a DNR status.
Inaccurate MDS Assessment of Resident's Dental Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the dental status of a resident, leading to a deficiency in the assessment process. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, was admitted with multiple missing and broken teeth. Despite informing multiple nursing staff about her dental condition and her desire to have her teeth extracted for dentures, the MDS assessment inaccurately recorded her as having natural teeth that were not broken, cracked, unclean, or loose. The Social Service Director (SSD) and the MDS Coordinator confirmed that the MDS and Nursing Admission Data Collection forms were incorrectly coded, failing to reflect the resident's actual dental status. The SSD and MDS Coordinator both acknowledged the discrepancy after reviewing the resident's medical record and conducting interviews with the resident, who demonstrated her dental issues. This inaccuracy in the MDS assessment could potentially delay or prevent the resident from receiving appropriate dental care.
Deficiency in Grooming and Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with grooming and nail care for two residents who were dependent on staff for activities of daily living. Resident #29, with severe cognitive impairment and functional limitations, was observed multiple times with long fingernails and beard growth, despite being dependent on staff for personal hygiene. The resident's care plan indicated that nail care should be provided on bathing days, yet documentation showed nail care was only provided once in a month. Staff acknowledged the resident's nails were long and needed trimming, but this was not consistently done. Resident #44, who had moderate cognitive impairment and required maximal assistance for personal hygiene, was also observed with long fingernails and facial hair growth. The resident expressed a need for assistance with showering and grooming. The care plan for Resident #44 did not specifically address nail care, and there was no documentation of nail care being provided over a month. Staff confirmed the resident's nails were long and needed trimming, and the resident was unable to perform these tasks independently. Interviews with staff, including the CNA and DON, revealed that the expectation was for residents to receive nail care on shower days. However, there was no specific policy for ADL and nail care, and it was included in the CNA's job description. The lack of consistent nail care and grooming for these residents indicates a deficiency in meeting the personal care needs of dependent residents, as outlined in their care plans.
Failure to Ensure Resident Participation in Activities
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident #24 and Resident #106, participated in activities of their choice, which is essential for maintaining and improving their psychosocial well-being and independence. Observations on multiple days revealed that both residents were consistently found in their rooms, in bed, without engaging in any in-room or out-of-room activities. The television or radio was not on, and there was no evidence of participation in any facility activity programs during the observed times. Resident #24 was admitted with several diagnoses, including anemia, end-stage renal disease, and heart failure, and had a care plan that required staff assistance for activity involvement. The care plan specified that the resident preferred afternoon activities, such as watching television, movies, and participating in group activities. However, documentation showed that the resident's activities were recorded as watching television early in the morning, without confirmation that these activities occurred. The Director of Activities (DOA) admitted to assuming that staff would turn on the television for the resident, without verifying or documenting the actual participation in activities. Similarly, Resident #106, who had a history of anxiety, aphasia, and cognitive communication deficits, was observed in her room without engaging in any activities. The resident's care plan indicated a preference for afternoon activities, including watching television, movies, and socializing outdoors. However, the activity records showed early morning documentation of activities that were not confirmed to have occurred. The DOA acknowledged not observing or confirming these activities, assuming that staff would facilitate them. This lack of oversight and documentation led to the deficiency in providing appropriate activities for the residents.
Failure to Assist Resident with Replacement of Lost Glasses
Penalty
Summary
The facility failed to provide timely assistance to a resident in obtaining replacement prescription glasses, which were lost. The resident, who had a history of impaired vision due to glaucoma, was observed multiple times without her glasses and reported that she had been without them for a while. Despite the resident's impaired cognition and her reliance on glasses to read and enjoy activities like artwork, there was no documented follow-up or action taken by the Social Services department to address the missing glasses. The facility's policy required prompt referrals for vision services, but this was not adhered to in the case of the resident. The resident's care plan initially included interventions to assist with cleaning and placing glasses, and to report any damage to the nurse or social service. However, the Social Services progress notes showed no issues reported since February, and the grievance log did not document any grievance or steps taken to replace the glasses. Interviews with the Social Service Director revealed a lack of awareness about the missing glasses, indicating a communication breakdown within the facility. The resident's need for glasses was documented by the eye doctor, but no appointment was arranged to replace them until the issue was brought to the attention of the Clinical Reimbursement Director.
Failure to Prevent Decline in Range of Motion
Penalty
Summary
The facility failed to provide adequate care and services to prevent a decline in range of motion for a resident with limited range of motion. The resident, who had severely impaired cognition and functional range of motion in both upper extremities, required substantial assistance for daily activities. Despite having a care plan that included the application of orthotic devices (splints) to prevent contractures, the resident was observed multiple times without the splints, and there was no documentation of refusal by the resident. The Treatment Administration Record indicated inconsistencies in the application of the splints, with staff failing to apply them as per the care plan. Interviews with staff revealed a lack of clarity and responsibility regarding the application of the splints. The Licensed Practical Nurse acknowledged that the splints were not always applied, and the Restorative CNAs were not working with the resident due to the assumption that the resident was receiving occupational therapy. However, the therapy records did not address the resident's hand contractures or the use of splints, and the therapy Program Manager confirmed that the resident was not receiving therapy for the contractures. The Director of Nursing was unable to provide notes related to the resident's condition, indicating a lack of oversight and documentation.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with federal regulations requiring the daily posting of nursing staff information. During observations on three consecutive days, the required staffing information was not posted or made available to residents and visitors. An interview with the Administrator revealed that the facility had not posted the required daily staffing information since February 29, 2024. The Administrator acknowledged the requirement to post this information daily in a prominent location within the facility.
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.
