Savoy At Fort Lauderdale Rehabilitation And Nursin
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Lauderdale, Florida.
- Location
- 2121 E Commercial Blvd, Fort Lauderdale, Florida 33308
- CMS Provider Number
- 105205
- Inspections on file
- 16
- Latest survey
- October 17, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Savoy At Fort Lauderdale Rehabilitation And Nursin during CMS and state inspections, most recent first.
The facility failed to provide closet doors or coverings in residents' rooms on the third floor, compromising the cleanliness and privacy of residents' clothing. Observations revealed disorganized clothing visible to residents and visitors. Interviews with CNAs indicated the issue had persisted for at least nine months. The Director of Maintenance confirmed the absence of closet doors during an environmental tour.
The facility was found to violate residents' dignity during care activities. A CNA referred to an adult brief as a 'diaper,' which a resident found disrespectful. An LPN administered medication in the hallway, potentially compromising a resident's privacy. Staff, including an RN/Unit Manager, referred to residents needing dining assistance as 'feeders,' contradicting the facility's dignity policy.
The facility failed to implement and develop care plans for residents, leading to deficiencies in care. Two residents were not properly supervised while smoking, contrary to their care plans. A resident with a urinary catheter experienced pain and bleeding without proper physician notification. Another resident with significant weight loss did not have their tube feeding adjusted, and a resident with PTSD lacked a specific care plan. These failures highlight the facility's inability to adhere to care plans and ensure resident safety.
A resident with a below-knee amputation experienced a sore that prevented the use of a prosthesis, leading to diminished abilities in activities of daily living (ADLs). Despite reporting the issue, the prosthesis was not adjusted, and the resident continued to experience pain. The Director of Rehabilitation and the occupational therapist were aware of the issue but failed to document or communicate effectively, resulting in a lack of follow-up and continued walking exercises.
Two residents in an LTC facility did not receive timely wound care as per physician orders. One resident with severe cognitive impairment had a skin tear on the elbow that was not treated daily as required, with staff failing to communicate and document care properly. Another resident with no cognitive impairment had an open sore from a prosthesis that was not identified or documented by nursing staff, despite the resident's complaints. The deficiencies were due to poor coordination and communication among staff.
A resident admitted with Stage 3 and Stage 4 pressure ulcers did not receive the recommended air mattress for treatment. Despite the care plan and evaluations indicating the need for an air mattress, the resident was observed on a standard mattress. The RN/Unit Manager acknowledged forgetting to order the air mattress, which was available on-site.
The facility failed to provide adequate supervision and safety measures for residents who smoke. A resident with a history of cerebral infarction and epilepsy was observed smoking with an unsecured apron and without consistent supervision, leading to a cigarette burn. Another resident with cognitive impairment was found smoking unsupervised and obtaining cigarettes from others. Additionally, a resident with a history of fractures had smoking materials unsecured at her bedside. The facility also left a supply room containing razors unlocked and unattended.
A resident with a history of UTI and acute kidney failure experienced inadequate catheter care and hand hygiene in an LTC facility. The CNA failed to perform hand hygiene between glove changes and did not report the resident's pain and bleeding during catheter care. Despite the facility's policy, there were no physician orders for catheter care documented initially, and the resident's pain was only addressed if requested.
The facility failed to provide appropriate care for residents on enteral feeding, leading to significant weight loss and improper feeding practices. A resident experienced a significant weight loss without adjustments to their feeding regimen, while another was improperly positioned during feeding. The facility's policies on enteral feeding and weight management were not effectively implemented, contributing to these deficiencies.
A facility failed to provide trauma-informed care for a resident with PTSD, as required by its policy. The resident, who was cognitively intact and had a history of seeing a psychologist, was not evaluated by a psychologist upon admission. Interviews revealed that the DON and SSD acknowledged the lack of psychological evaluation and consultation, despite the resident's PTSD diagnosis.
The facility failed to obtain orders, develop care plans, and inspect bed rails for two residents. One resident, cognitively intact, had bed rails without documentation or need, while another, severely impaired, had rails despite lacking mobility to use them. Maintenance did not regularly inspect rails, contributing to the deficiency.
The facility failed to reconcile controlled medications accurately and remove discontinued medications for two residents. Discrepancies were found between the MAR and Medication Monitoring/Control Record for Tramadol administration. Staff interviews revealed inconsistencies in the reconciliation process, with no random periodic checks by management.
A facility failed to monitor a resident's antipsychotic medication for side effects and behaviors. Despite a care plan requiring such monitoring, there was no documentation of it in the MAR, and the consultant pharmacist did not recommend it. Interviews with staff confirmed the absence of monitoring orders, and the resident reported not being asked about side effects.
The facility failed to securely store medications for two residents. A nurse left medications unattended for one resident, and another resident had eye drops at the bedside without a doctor's order. Both instances violated the facility's medication storage policy.
The facility failed to serve the correct portions of pureed food, affecting residents with puree diet orders. A cook used a 4-ounce scoop for both regular and pureed beef stew, despite the menu requiring 6 ounces for puree diets. This was confirmed during a kitchen tour, and the issue was acknowledged by the Dietetic Tech / Kitchen Supervisor and the Regional Dietary Manager.
The facility failed to prepare pureed carrots according to the approved recipe, resulting in a soupy consistency that diminished their nutritional value. This affected residents on pureed diets, as the preparation method involved adding water to frozen carrots, contrary to the recipe's instructions. The issue was acknowledged by the Dietetic Tech / Kitchen Supervisor and the Regional Dietary Manager during a kitchen tour.
The facility failed to prepare pureed vegetables to meet the required consistency for residents on pureed diets. During a kitchen tour, surveyors observed that the pureed carrots were soupy and did not hold the necessary texture, affecting 14 residents. The issue was acknowledged by the Dietetic Tech and Regional Dietary Manager.
The facility was found to have multiple deficiencies in kitchen sanitation and food safety, including inadequate hand washing water temperature, improper storage of partially raw chicken, and insufficient dishwasher temperatures. Additionally, there was residue on fire suppression pipes, wet nesting of sanitized pans, and food debris on slicer equipment. These issues were acknowledged by the kitchen staff and management.
The facility failed to manage its resources effectively, leading to an unsafe environment. An Administrator, also the Risk Manager, did not recall a cigarette burn incident involving a resident until prompted by a surveyor. The Administrator admitted to not reviewing the incident or ensuring interventions were implemented, as focus was diverted to another investigation. Additionally, smoking risk evaluations were not conducted quarterly, and key staff turnover may have contributed to the oversight.
The facility failed to maintain a functioning emergency call system in several resident bathrooms, with missing pull cords observed in multiple rooms. Staff were unaware of the deficiency, and the issue was confirmed by the Director of Maintenance during an inspection.
The facility failed to post accurate nursing staffing information before each shift, leading to discrepancies between scheduled and actual staffing levels. The postings were based on scheduled hours, not actual hours worked, and were not updated to reflect changes such as call-offs. The Staffing Coordinator and Receptionist confirmed these inaccuracies, and the Administrator acknowledged the issue.
A staff member in an LTC facility was observed on video surveillance abusing three cognitively impaired residents. The abuse included forceful handling, threatening gestures, and physical strikes. The residents, who were severely cognitively impaired, were unable to report the abuse due to their condition. The facility's policy prohibits such abuse, yet the staff member's actions resulted in physical and mental harm to the residents.
A facility failed to report suspected abuse within the required 2-hour timeframe after discovering a CNA had abused three residents. The NHA initially believed an injury was self-inflicted but later found evidence of abuse through surveillance footage. The incident was reported 24 hours after discovery, outside the mandated window, due to the NHA's oversight of the reporting requirement.
Lack of Closet Doors on Third Floor
Penalty
Summary
The facility failed to ensure that the closet space in residents' rooms on the third floor had doors or coverings, which compromised the cleanliness, protection, and privacy of residents' clothing. During an initial tour, it was observed that all residents' rooms on the third floor were missing closet doors, leaving personal clothing and items exposed. In several rooms, clothing was found disorganized and visible to residents and visitors. Interviews with two Certified Nursing Assistants (CNAs) revealed that the closets had been without doors or coverings for at least nine months to a year. The Director of Maintenance confirmed the absence of closet doors or coverings during an environmental tour.
Dignity Violations in Resident Care
Penalty
Summary
The facility failed to uphold the dignity of residents during care activities, as observed in several instances. During catheter care for a resident, a CNA referred to an adult brief as a 'diaper,' which the resident found disrespectful. The CNA, who had been employed at the facility for four months, did not recognize the term as inappropriate. Additionally, a resident was administered medication in the hallway by an LPN, who stated that this was a common practice if the resident requested it. However, the resident involved did not confirm that it was her choice, indicating a potential lack of respect for her privacy and dignity. Furthermore, staff members were observed referring to residents needing dining assistance as 'feeders,' a term that was used by both an LPN and an RN/Unit Manager. This terminology was justified by the staff as necessary for clear communication, especially with non-English speaking staff, but it contradicts the facility's policy on treating residents with dignity and respect. The RN/Unit Manager was unaware of the policy against labeling residents in such a manner, highlighting a gap in staff training and awareness regarding the facility's dignity policy.
Failure to Implement and Develop Care Plans
Penalty
Summary
The facility failed to implement and develop care plans for several residents, leading to deficiencies in care. For two residents who were reviewed for smoking, the facility did not properly implement care plans. One resident was found to have cigarettes, a lighter, and a vaping device at the bedside, contrary to the care plan that required these items to be secured. The resident reported that staff were aware of this and did not consistently supervise smoking. Another resident, who was supposed to be supervised while smoking and required a smoking apron, was observed smoking without supervision and lighting her own cigarette, despite the care plan indicating she could not light her own cigarette. The facility also failed to implement a care plan for a resident with an indwelling urinary catheter. The resident experienced pain and bleeding during catheter care, but there was no documentation of the nurse contacting the physician to report these issues. The care plan included monitoring for signs of urinary infection and discomfort, but these interventions were not adequately followed, as evidenced by the resident's pain and the lack of communication with the physician. Additionally, the facility did not develop a care plan for a resident with significant weight loss and receiving tube feedings. The resident experienced a significant weight loss, and the spouse expressed concerns about the resident not receiving the full tube feeding. The care plan aimed for weight gain, but the interventions were not adjusted despite the resident's weight loss. Furthermore, a resident with a diagnosis of PTSD did not have a care plan addressing this condition, as the staff believed it was covered under other diagnoses. The lack of a specific care plan for PTSD meant that individualized interventions were not implemented.
Failure to Address Prosthesis Issues Leads to Diminished ADL Abilities
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident's abilities in activities of daily living (ADLs) did not diminish. The resident, who had a below-knee amputation and used a prosthesis, was observed to have a sore behind the knee, which prevented the use of the prosthesis for about a week or ten days. Despite the resident's report of the sore to the nurse and therapist, the prosthesis was not adjusted, and the resident continued to experience pain when using it. The resident was discharged from physical therapy and was receiving occupational therapy, but there was no referral to restorative care to continue walking exercises. The Director of Rehabilitation (DOR) and the occupational therapist were aware of the resident's issues with the prosthesis but did not document or communicate these concerns effectively. The DOR did not notify the nurse about the resident's sore, and the occupational therapist did not document the resident's complaints about the prosthesis. The resident expressed a desire to walk and had previously been able to walk 150 feet with supervision before the issues with the prosthesis arose. The lack of communication and follow-up on the resident's prosthesis concerns contributed to the resident's diminished ability to perform ADLs.
Failure to Provide Timely Wound Care for Residents
Penalty
Summary
The facility failed to provide appropriate care and services for two residents with skin conditions. For Resident #63, who has severe cognitive impairment and requires substantial assistance with activities of daily living, the facility did not follow the physician's orders for wound care. The resident had a skin tear on the left elbow that was supposed to be treated daily, but the dressing was not changed as required. Observations revealed that the dressing was dated several days prior, and interviews with staff indicated confusion and lack of communication regarding who was responsible for the wound care. Staff members admitted to signing off on the treatment administration record without actually performing the care, assuming it was done by the wound care nurse. Resident #80, who has no cognitive impairment and is dependent on staff for certain activities, was found to have an open sore behind the right knee where a prosthesis sits. Despite the resident's complaints of pain and the sore being visible, the nursing staff failed to identify and document the wound in a timely manner. The resident reported the issue to a therapist, but the information was not communicated to the nursing staff. Observations and interviews revealed that the sore was not documented in the weekly skin evaluation, and the resident expressed concerns about the sore worsening. The deficiencies highlight a lack of coordination and communication among the facility's staff regarding wound care responsibilities and documentation. Both residents experienced delays in receiving appropriate care for their skin conditions, which were not promptly identified or treated according to the physician's orders and care plans. The facility's failure to adhere to established protocols and ensure proper communication among staff members contributed to the deficiencies observed during the survey.
Failure to Provide Recommended Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident admitted with a Stage 4 pressure ulcer. Upon admission, the resident was documented as being bed-bound and had a Stage 4 pressure injury to the sacrum and a Stage 3 pressure injury to the right gluteal area. The care plan included interventions such as monitoring for signs of infection and assisting the resident in changing positions. A Skin and Wound Evaluation recommended the use of an air mattress as part of the treatment for the pressure injuries. Despite the recommendation for an air mattress, the resident was observed on multiple occasions to be on a standard mattress. Interviews with the resident and staff confirmed that the air mattress had not been ordered or provided, despite being available on-site. The RN/Unit Manager admitted to forgetting to order the air mattress, resulting in the resident continuing to use a standard mattress, which was contrary to the care plan and recommendations for pressure ulcer management.
Inadequate Supervision and Safety Measures for Smoking Residents
Penalty
Summary
The facility failed to ensure adequate protection and supervision for residents who smoke, as evidenced by multiple observations and interviews. Resident #19, who has a history of cerebral infarction, diabetes, and epilepsy, was observed smoking with an unsecured smoking apron, allowing ashes to fall onto the ground. Despite the facility's policy requiring supervision, Resident #19 reported that staff only occasionally supervised her smoking sessions. Additionally, her smoking risk was not re-evaluated quarterly, and she had previously sustained a cigarette burn on her thigh, indicating a lack of consistent monitoring and adherence to safety protocols. Resident #249, with diagnoses including thyrotoxicosis, diabetes, and Parkinson's disease, was also observed smoking unsupervised. The resident, who has moderately impaired cognition, reported obtaining cigarettes from other residents, contrary to the facility's policy. The care plan for Resident #249 required supervision and assistance to light cigarettes, yet observations showed a lack of staff presence during smoking activities. Resident #8, with a history of fractures, anxiety, and muscle weakness, was found with smoking materials at her bedside, which should have been secured according to the facility's policy. Despite being assessed as needing supervision, Resident #8 reported that staff did not consistently supervise her smoking. Additionally, the facility failed to secure a supply room containing razors, which was found unlocked and unattended, posing a potential hazard.
Deficiency in Catheter Care and Hand Hygiene
Penalty
Summary
The facility failed to provide appropriate catheter care and hand hygiene for a resident, leading to a deficiency in care. The resident, who had a history of urinary tract infection and acute kidney failure, was observed to have an indwelling urinary catheter. Despite the facility's policy requiring catheter care every shift, there were no physician orders for catheter care documented from the resident's readmission until several days later. Additionally, the Treatment Administration Record showed no documentation of catheter care during this period. During an observation of catheter care, a Certified Nursing Assistant (CNA) was seen changing gloves multiple times without performing hand hygiene, contrary to the facility's hand hygiene policy. The CNA also failed to report the resident's pain and bleeding during catheter care to the nurse, assuming the nurse was already aware. The resident expressed experiencing pain during the procedure, and the CNA acknowledged that hand sanitizer was not available, which contributed to the lack of proper hand hygiene. Interviews with the resident and staff revealed that the resident had been experiencing pain with catheter care, and although pain medication was available, it was only administered upon request. The Registered Nurse confirmed that catheter care was supposed to be performed every shift, but there was a lack of communication and documentation regarding the resident's pain and bleeding, which were not reported to the physician as required by the facility's policy.
Deficiencies in Enteral Feeding and Weight Management
Penalty
Summary
The facility failed to provide appropriate care and services for residents receiving enteral feeding, leading to significant weight loss and improper feeding practices. Resident #90, who was admitted with multiple diagnoses including Progressive Supranuclear Ophthalmoplegia, Dysphagia, and Parkinson's Disease, experienced a significant weight loss of 10.87% within a short period. Despite the resident's husband expressing concerns about weight loss and the resident's inability to swallow, the facility did not adjust the tube feeding orders or update the care plan to address the weight loss. Observations revealed inconsistencies in the administration of tube feeding, with the resident not receiving the full prescribed amount. Resident #199, who was severely cognitively impaired and dependent on staff for all activities of daily living, was observed receiving enteral feeding while lying in a nearly supine position, contrary to the physician's order to keep the head of the bed elevated at 30-45 degrees. This improper positioning was confirmed by staff, indicating a failure to adhere to prescribed feeding protocols designed to prevent complications. The facility's policies on enteral feeding and weight management were not effectively implemented, as evidenced by the lack of timely interventions and adjustments to feeding regimens in response to significant weight changes. The Registered Dietician did not take action to address the weight loss, relying instead on information from the resident's husband rather than documented weights. This inaction contributed to the deficiencies observed in the care of residents receiving enteral nutrition.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD), as required by professional standards. The facility's policy on Trauma-Informed and Culturally Competent Care mandates minimizing triggers and re-traumatization for trauma survivors. However, the facility did not conduct a psychology evaluation for the resident upon admission, despite her psychological diagnoses, including PTSD. The resident, who was cognitively intact, expressed a desire to continue seeing a psychologist, as she had before her admission, but had not been evaluated or treated by a psychologist since her admission. Interviews with facility staff revealed a lack of adherence to the facility's policy. The Director of Nursing (DON) acknowledged that the resident had not been seen by a psychologist since her admission. The Social Services Director (SSD) admitted that the resident's PTSD diagnosis was not addressed, as there were no observed changes in mood or signs of PTSD. The SSD also confirmed the absence of any psychology consultation for the resident, despite the facility's policy requiring such evaluations for residents with psychological diagnoses.
Failure to Properly Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to obtain orders for bed rails, develop and implement a care plan for their use, and regularly inspect the rails for fit and function for two residents. Resident #197, who was cognitively intact and required moderate assistance for bed mobility, had bed rails installed without any documented orders or care plan. The resident stated that they did not use the bed rails, and the therapy staff indicated that the resident was high-functioning and had been recommended for bed rails without proper documentation. Resident #199, who was severely cognitively impaired and dependent on staff for all activities of daily living, also had bed rails installed without orders or a care plan. The resident's family member noted that the resident lacked the upper body mobility to use the rails, and the occupational therapist confirmed that the rails were not indicated due to the resident's limited mobility and potential risk of entrapment. Despite this, the resident was observed with raised bed rails during the survey. The facility's maintenance department failed to conduct regular inspections of bed rails for residents who were not discharged. The Maintenance Director admitted that audits were not being performed, and a blank spreadsheet intended for audits was provided to the surveyor. This lack of regular inspection and documentation contributed to the deficiency in ensuring the safety and appropriateness of bed rail use for the residents.
Controlled Medication Reconciliation Failure
Penalty
Summary
The facility failed to accurately reconcile controlled medications and ensure discontinued controlled medications were removed from the medication cart for two residents. For Resident #33, there was a discrepancy between the Medication Administration Records (MAR) and the Medication Monitoring/Control Record regarding the administration of Tramadol. The MAR indicated that Tramadol was administered on several dates, some with a pain level of 0, while the Medication Monitoring/Control Record showed additional administrations not recorded in the MAR. For Resident #41, the MAR showed no administration of Tramadol prior to its discontinuation date, yet the Medication Monitoring/Control Record indicated that Tramadol was administered after the discontinuation date. This discrepancy highlights a failure in the facility's protocol for documenting and reconciling controlled medications. Interviews with staff revealed a lack of clarity and consistency in the reconciliation process. The Director of Nursing (DON) was unsure if a specific policy for reconciliation existed and confirmed that controlled medication counts were conducted at every shift change. However, there was no random periodic reconciliation by unit managers or the DON, indicating a gap in oversight and adherence to the facility's policies on controlled substances.
Failure to Monitor Antipsychotic Medication Side Effects
Penalty
Summary
The facility failed to adequately monitor a resident's drug regimen for side effects and behaviors associated with antipsychotic medication. Resident #70, who was admitted with diagnoses including Bipolar Disorder, Psychosis, Anxiety Disorder, and PTSD, was prescribed Aripiprazole for psychosis. Despite the care plan's goals to keep the resident free from drug-related complications and to monitor for side effects, there was no documentation in the September Medical Administration Record (MAR) of such monitoring. Additionally, the consultant pharmacist did not recommend monitoring for side effects or behaviors in their medication regimen reviews from May to September 2024. Interviews with facility staff, including the consultant pharmacist, MDS Coordinator, Director of Nursing, and Social Services Director, revealed a lack of orders or documentation for monitoring the resident's behavior and side effects. The resident herself confirmed that she had never been asked about her behavior or medication side effects. The Director of Nursing acknowledged that the resident had not been seen by a psychologist since admission, and the Social Services Director could not find any psychology consultations for the resident.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored securely for two residents, leading to deficiencies in medication management. For Resident #246, during a medication pass, a registered nurse placed several medications on the resident's overbed table and left them unattended while she went into the bathroom to wash her hands. This included Diclofenac Sodium topical gel, which was left on the table even after the nurse returned and administered the other medications. The nurse acknowledged that she should not have left the medications unattended, indicating a lapse in following the facility's policy on medication storage. In another instance, Resident #8 was observed with Systene Complete PF eye drops on the overbed table in plain sight on two separate occasions. During an interview, the resident mentioned using the eye drops every night for dry eyes. However, the unit manager confirmed that residents should not have medications at the bedside without a doctor's order. The eye drops were subsequently removed by the unit manager, highlighting a failure to adhere to the facility's medication storage policy.
Deficiency in Pureed Food Portioning
Penalty
Summary
The facility failed to provide the correct portions of pureed food according to the approved menu, potentially affecting 14 residents with puree diet orders. During a kitchen tour, it was observed that Staff F, a cook, used a 4-ounce scoop for both regular and pureed portions of beef stew, despite the menu specifying 6 ounces for puree diets. This discrepancy was confirmed when the portion of pureed beef stew was weighed and found to be 4 ounces instead of the required 6 ounces. The Dietetic Tech / Kitchen Supervisor and the Regional Dietary Manager acknowledged that the residents with puree diet orders were not being served according to the approved menu.
Deficiency in Pureed Carrot Preparation
Penalty
Summary
The facility failed to prepare pureed vegetables, specifically carrots, in a manner that preserved their nutritive value, affecting residents on pureed diets. During a kitchen tour, surveyors observed that the pureed carrots were soupy and did not meet the required consistency standards for Puree Level 4. The carrots were prepared by using frozen carrots, thawed and blended with water, which resulted in a diluted product that pooled in the serving bowl. This preparation method did not adhere to the facility's recipe, which required the addition of other vegetables and ingredients to maintain nutritional value. The Dietetic Tech / Kitchen Supervisor and the Regional Dietary Manager acknowledged the issue during the observation. The staff member responsible for preparing the carrots, identified as Staff B, confirmed that only water was added to the carrots to achieve the observed consistency. This practice led to a reduction in the nutritional content of the carrots, potentially affecting 14 residents with orders for pureed diets. The facility's failure to follow the approved recipe for carrots could impact all residents consuming meals from the approved menu.
Failure to Prepare Pureed Vegetables to Required Consistency
Penalty
Summary
The facility failed to prepare pureed vegetables in a form that met the individual needs of residents requiring pureed diets. During a kitchen tour, surveyors observed that the pureed carrots were soupy and did not hold the required consistency as per the facility's recipe instructions. The pureed carrots were supposed to have a specific texture that did not separate, was not sticky, and could not be drunk from a cup or sucked through a straw. However, the carrots were observed to be sloshing in the pan and pooling in the bowl, indicating they did not meet the required consistency. This deficiency had the potential to affect 14 residents with orders for pureed diets, including specific residents identified in the report. The Dietetic Tech / Kitchen Supervisor and the Regional Dietary Manager acknowledged the issue during the observation. The deficiency was noted when Staff B, the cook, was preparing the pureed carrots, and it was evident that the carrots did not hold the shape and consistency required for pureed foods.
Deficiencies in Kitchen Sanitation and Food Safety
Penalty
Summary
The facility failed to prepare, store, and serve meals in a safe and sanitary manner, as observed during a kitchen tour. The surveyor noted several deficiencies, including the failure of the hot water at the designated hand washing sink to reach the appropriate temperature for hand hygiene. In the walk-in cooler, a full-sized pan of partially raw chicken was stored above ready-to-eat deli meats, posing a risk of cross-contamination. Additionally, a damp towel was found on the handles of the convection oven, used as a reminder for food still in the oven, which is not a sanitary practice. Further observations included an accumulation of residue on the pipes of the fire suppression system over the cooking equipment and wet nesting of cleaned and sanitized hotel pans on the sanitizing shelf. The slicer blade and sharpening stones had food residue and debris, indicating improper cleaning. The mechanical dishwasher's hot water temperature was insufficient, failing to reach the required 120 degrees Fahrenheit for proper cleaning and sanitization, with temperatures observed between 88 to 90 degrees Fahrenheit. These findings were acknowledged by the Dietetic Tech/Kitchen Supervisor and the Regional Dietary Manager.
Failure to Address Smoking Hazards and Incident Follow-Up
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in an environment not free of accident hazards. The Administrator, who also serves as the Risk Manager, did not recall an incident involving a cigarette burn sustained by a resident until prompted by a surveyor. This incident occurred on the smoking patio, where residents were allowed to smoke. The Administrator admitted to not reviewing the incident or ensuring that any interventions were implemented following the event. At the time, the facility was dealing with another issue under investigation, which diverted the Administrator's focus. Additionally, the Administrator acknowledged that residents were using the smoking patio at various times, with all but one being considered safe smokers. However, she was unaware that smoking risk forms and evaluations were not being conducted quarterly as required. The facility experienced turnover in key staff positions, including the Director of Nursing and several other staff members, in the weeks following the incident, which may have contributed to the oversight and lack of follow-up on the incident.
Deficiency in Emergency Call System in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the bathrooms in residents' rooms were equipped with a functioning emergency call system. During an initial tour, it was observed that several rooms on the 2nd and 3rd floors were missing the pull cords necessary for the emergency call light system. Specifically, rooms 222, 232, 304, 307, and 314 were identified as lacking these essential safety features. Additionally, in one room, the pull cord was found wrapped around a grab bar, rendering it inaccessible to residents. These observations were confirmed during a follow-up inspection, where the missing pull cords were still not addressed. Interviews with staff members revealed a lack of awareness regarding the missing pull cords. Staff P, a CNA, acknowledged that residents in her care required assistance with toileting and relied on verbal communication to signal when they needed help. Staff Z, another CNA, was unaware of the missing pull cord in the bathroom of the resident she assisted, only realizing the deficiency when prompted by the surveyor. The Director of Maintenance confirmed the absence of the pull cords during an environmental tour, acknowledging the oversight in maintaining the emergency call system in residents' bathrooms.
Inaccurate Nursing Staffing Postings
Penalty
Summary
The facility failed to post accurate and current nursing staffing information before the beginning of each shift, as required. Observations on multiple dates revealed that the nursing staffing postings were outdated, with postings from the previous day still displayed at the start of the new shift. Interviews with the Staffing Coordinator and the Receptionist confirmed that the postings were based on scheduled hours rather than actual hours worked, leading to inaccuracies. The Staffing Coordinator was responsible for providing the receptionist with the nursing staff schedule, who then posted the information. However, the receptionist's job description did not include the responsibility of creating and posting nursing schedules, which contributed to the inaccuracies. The Staffing Coordinator admitted that the postings were not updated to reflect changes such as call-offs or additional staff, resulting in discrepancies between the posted and actual staffing levels. A review of random sampled nursing staffing hours against the Scheduling Master spreadsheet highlighted several instances where the posted information did not match the actual staffing levels. For example, on multiple occasions, the number of CNAs scheduled was incorrect, and the hours for certain shifts were inaccurately reported. The Administrator acknowledged that the receptionist had always completed the nursing staff postings, but the inaccuracies were not addressed, leading to the deficiency.
Abuse of Cognitively Impaired Residents by Staff Member
Penalty
Summary
The facility failed to protect the rights of three cognitively impaired residents from mental and physical abuse by a staff member. The incident involved a Certified Nursing Assistant (CNA), identified as Staff A, who was observed on video surveillance engaging in abusive behavior towards the residents. The abuse included forcefully handling the residents, making threatening gestures, and physically striking one resident. The residents involved were severely cognitively impaired, with Brief Interview for Mental Status (BIMS) scores indicating severe cognitive impairment. Resident #1, who was involved in the incident, had a BIMS score of 00/15 and was diagnosed with conditions such as Atrial Fibrillation, Hypertension, and Anxiety Disorder. During the incident, Staff A was seen violently handling Resident #1, including hitting him in the back with her elbow and forearm. Resident #1 attempted to stand multiple times and was met with aggressive actions from Staff A, which included poking him in the arm and face, causing his glasses to fall. The video did not capture any nurse involvement at the time of the incident. Resident #2 and Resident #3, both with severe cognitive impairments, were also subjected to rough handling by Staff A. Resident #2 was roughly moved and pushed back into his wheelchair, while Resident #3 was aggressively stopped from moving and faced threatening gestures. The facility's policy strictly prohibits abuse of any kind, yet the actions of Staff A violated this policy, resulting in physical and mental harm to the residents.
Failure to Timely Report Abuse
Penalty
Summary
The facility failed to report suspected abuse within the required 2-hour timeframe after being made aware of the incident involving three residents. The Nursing Home Administrator (NHA) was informed of an injury to a resident's forehead, initially believed to be self-inflicted. However, upon further investigation, including a review of surveillance footage, it was discovered that a Certified Nursing Assistant (CNA), identified as Staff A, had physically and mentally abused three residents. The NHA admitted to forgetting the requirement to report the abuse within 2 hours of notification. The incident was reported to the federal authorities 24 hours after the discovery of the abuse, which was outside the mandated reporting window. The NHA was initially informed of the incident on May 10, 2024, but the federal report was not submitted until May 11, 2024. The delay in reporting was due to the NHA's oversight of the reporting requirement, despite the facility's policy clearly outlining the need for timely reporting of abuse incidents.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
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