South Heritage Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Petersburg, Florida.
- Location
- 718 Lakeview Ave S, Saint Petersburg, Florida 33705
- CMS Provider Number
- 105117
- Inspections on file
- 17
- Latest survey
- October 15, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at South Heritage Health & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that two residents experienced multiple medication errors, including late administration, incorrect medication, improper insulin administration due to lack of pen needles, and failures in hand hygiene and documentation. LPNs did not follow manufacturer or facility protocols, and the DON was unaware of ongoing supply issues, resulting in a medication error rate of 68.18%.
Surveyors found that staff failed to follow infection control protocols, including leaving an insulin syringe unsheathed on multiple surfaces, not using a barrier on an over bed table, neglecting hand hygiene and glove use during eye drop administration, and having direct care nurses with excessively long fingernails. These actions were confirmed by staff and contradicted both facility policy and CDC guidance.
Surveyors found unsanitary conditions in the main shower room and two shared bathrooms, including hair, debris, and bio-growth on floors and equipment. Housekeeping staff reported inconsistent cleaning routines and unclear responsibilities for shower maintenance, resulting in a failure to meet facility policy for a clean and comfortable environment.
A resident with multiple health issues experienced an unwitnessed fall and was assisted back to bed by staff without a documented assessment or evaluation for injuries. Despite ongoing complaints of pain reported by the roommate, staff did not document the incident or order an X-ray until two days later, which revealed a hip fracture requiring surgery. Facility protocols for post-fall assessment and notification were not followed, resulting in delayed identification and treatment of the injury.
A resident who was dependent for transfers and required a mechanical lift with two staff assistance was transferred by a single CNA, contrary to the care plan and facility policy. During the transfer, the resident fell and sustained a significant femur fracture, with investigation confirming that the required two-person assistance was not provided.
The facility did not ensure an RN was on duty for eight consecutive hours each day as required, with staff schedules showing only LPNs present and the RN's name crossed out. The DON confirmed gaps in RN coverage due to call-offs and lack of real-time monitoring, despite facility policy requiring daily staffing evaluation.
A resident with significant mobility impairments suffered a severe leg fracture after being transferred by a single CNA without the required use of a mechanical lift and two-person assistance. There were also multiple discrepancies in the documentation of controlled medication administration, and the resident's emergency contact was not notified following a hospital transfer after the fall, contrary to facility policy.
A resident with multiple medical conditions experienced a fall and was transferred to the hospital, but the facility did not notify the designated emergency contact or document such notification. The family only became aware of the hospitalization after being informed by the resident herself, and facility records lacked evidence of required communication with the family, despite policy mandating notification and documentation.
A resident who was cognitively intact and dependent on staff for transfers after recent leg surgery received oxycodone for pain, but staff failed to accurately document administration of the medication. Multiple doses were recorded on the controlled drug inventory sheets but not on the MAR, and there were inconsistencies in administration times between records. The DON confirmed these discrepancies, which were not in line with facility policy requiring immediate and accurate documentation of controlled substances.
The facility's dishwashing machine was found to have an excessively high concentration of chemical chlorine sanitizer, exceeding the required range of 50-100 ppm. Despite this, the machine continued to be used for meal services without corrective action. The issue was previously cited during a health inspection, but no in-services or education were provided to staff, and the Dietary Manager lacked access to the machine's operations manual or policy.
The facility failed to maintain a sanitary and safe environment, with observations of unsanitary conditions and broken fixtures across two units. Issues included brown substances around toilets, bio-growth on shower chairs, and malfunctioning fixtures. Maintenance and housekeeping staff were unaware of these problems, indicating a breakdown in communication and oversight.
Two residents experienced unresolved grievances related to their wheelchairs. One resident's wheelchair was lost during a hurricane evacuation and was not replaced with a suitable one, while another resident faced issues with wheelchair bearings that were not addressed despite repeated requests. The facility's grievance log did not accurately reflect these concerns, and no effective resolution was provided.
The facility failed to ensure proper medication storage and security across all units. Expired and improperly stored medications were found in medication carts, and unsecured medications were accessible in an office. Additionally, residents had medications in their rooms without authorization for self-administration, violating the facility's policy.
The facility failed to ensure accurate PASARR Level I screens for three residents, leading to deficiencies. A resident with PTSD and depression, another with depression, and a third with anxiety disorder had screens that did not reflect their mental health diagnoses. The DON confirmed the inaccuracies, and the Admission Director admitted to not checking for accuracy due to lack of training.
A resident with a history of muscle wasting and impaired mobility was not provided with a contracture management care plan, resulting in a deficiency. Despite having a prescribed right-hand splint, the resident was observed multiple times without it, and there was no documentation of its use. Interviews revealed that the resident was aware of the splint's purpose but was not assisted by staff in wearing it. Occupational therapy staff were responsible for its application, but there was no documentation of consistent use.
A resident in a long-term care facility did not receive necessary nail care assistance, resulting in long, untrimmed nails with debris. Despite the resident's desire for nail care, there was no documentation of care being provided or refused. The care plan lacked specific instructions for nail care refusal, and staff interviews revealed challenges in providing care due to the resident's refusals. The facility's policies required documentation of refusals, but this was not consistently done, and grievances regarding nail care were not adequately addressed.
A resident with a history of malignant neoplasm of the larynx and COPD did not receive enteral nutrition as ordered, with the feeding pump often found off and not running. Despite orders for continuous feeding at 65 ml/hr, observations confirmed the feeding was not administered as prescribed. Staff interviews revealed awareness of the orders, but the feeding was not ensured, leading to a deficiency in care.
The facility failed to implement pharmacy recommendations for two residents, leading to deficiencies in medication management. A resident with COPD did not have a recommended reminder to rinse the mouth after using an inhaler added to their physician's order. Another resident with multiple diagnoses had several pharmacy recommendations unaddressed, including clarifying medication orders and evaluating medication use due to fall risk. The DON confirmed these recommendations were not followed up with the physician.
A facility experienced a 10% medication error rate due to three incidents involving incorrect medication administration. An LPN administered the wrong medication to a resident due to similar packaging, another resident missed a dose of Entresto due to a reorder delay, and a third resident received an incorrect dosage of Risperidone due to a charting system error. The errors were acknowledged by staff, and the Director of Nursing reviewed the issues.
A resident with scabies did not receive proper infection control measures, as prescribed treatments were not administered, and staff were unaware of the diagnosis. The facility failed to implement isolation and cleaning protocols, leading to a deficiency in infection control practices.
Medication Error Rate Exceeds 5% Due to Improper Administration and Documentation
Penalty
Summary
Surveyors identified that the facility failed to maintain a medication error rate below 5%, with observations revealing a 68.18% error rate during medication administration to two residents. During medication passes, staff administered incorrect medications, failed to follow manufacturer instructions for insulin administration, and did not adhere to facility policy regarding hand hygiene and documentation. Specifically, one LPN used an insulin syringe to extract insulin from a pen, contrary to manufacturer warnings and facility policy, due to a lack of appropriate pen needles. The same staff member also administered a probiotic that was not the one ordered and failed to notify the physician about late or missed medications. Another LPN was observed administering multiple medications late, failing to perform hand hygiene or wear gloves when administering eye drops, and documenting that a resident received medication that was actually refused. Additionally, scheduled doses of inhaled medications and topical treatments were not administered as ordered, and documentation did not reflect accurate administration times or refusals. Interviews with staff confirmed that medication administration was delayed due to staffing issues and meetings, and that there had been an ongoing shortage of insulin pen needles, which had not been adequately addressed by facility leadership. Review of facility policies showed clear requirements for medication administration timing, hand hygiene, and proper use of insulin pens, none of which were consistently followed. The DON and other staff acknowledged the lack of pen needles and the resulting improper insulin administration practices, as well as gaps in communication with pharmacy and among staff. The pharmacy confirmed a recent shortage of pen needles, but the facility had not implemented alternative solutions or ensured compliance with safe medication administration practices.
Failure to Implement Effective Infection Control Practices During Medication Administration
Penalty
Summary
Surveyors observed multiple failures in the facility's infection prevention and control practices during medication administration and resident care. One staff member was seen extracting insulin with a safety sheath syringe, then placing the unsheathed needle on various surfaces, including a mouse pad and a medication blister card, before entering a resident's room. The same staff member placed the unsheathed syringe, along with a cup of water and a glucometer, directly on a resident's over bed table without using a barrier. These actions were confirmed by the staff member when questioned. Another staff member was observed with natural fingernails extending approximately half an inch past the fingertips, which is contrary to facility policy and CDC guidance. This staff member administered multiple medications, including eye drops, to a resident without performing hand hygiene or donning gloves. The staff member acknowledged not using hand sanitizer and not wearing gloves during the administration of eye drops. Additionally, a unit manager was observed with similarly long, painted fingernails, further indicating non-compliance with infection control standards. The Director of Nursing confirmed that hand hygiene is required before and after glove use and during medication administration, but was uncertain about the specific policy on fingernail length. Review of the facility's employee handbook and infection prevention policy revealed requirements for short, clean fingernails and no artificial nails, as well as comprehensive infection control measures. CDC guidance also emphasizes the importance of hand hygiene and maintaining short natural nails to prevent the spread of infection.
Failure to Maintain Sanitary and Homelike Environment in Shared Shower Areas
Penalty
Summary
Surveyors observed that the facility failed to maintain a sanitary and homelike environment in the main shower room and two shared bathrooms. Specific findings included clumps of hair and debris in the main shower room drain, a shower chair with a cup containing a green substance and black particles, and black debris inside a bedpan left on a shower chair. Additional observations revealed multiple strands of hair and areas of black and green bio-growth on the floors and tiles in the shared bathrooms. These unsanitary conditions were present in three out of thirteen rooms with shared bathrooms. Interviews with housekeeping staff revealed inconsistent cleaning practices and unclear responsibilities regarding the cleaning of showers and shower chairs. One staff member stated he only cleaned toilets and mirrors, while another indicated that CNAs were responsible for cleaning after each resident and that he only performed basic cleaning unless notified of an issue. The housekeeping supervisor confirmed that showers should be cleaned regardless of use and that the observed bio-growth would not have developed overnight. Facility policy requires a safe, clean, and comfortable environment, including clean resident care equipment, but these standards were not met in the areas observed.
Failure to Assess and Respond to Resident Fall Resulting in Delayed Treatment
Penalty
Summary
A resident with multiple medical conditions, including dementia, muscle weakness, osteoarthritis, and a history of falls, experienced an unwitnessed fall in their room. The resident's roommate reported hearing a loud noise and the resident expressing pain, after which she activated the call light and called for staff assistance. Staff response was delayed, and when they arrived, the resident was assisted back to bed without a documented assessment or evaluation for injuries as required by facility protocol. No documentation of the fall or post-fall assessment was found in the medical record for the date of the incident. Over the following days, the resident continued to complain of hip pain, which was reported by the roommate to staff on multiple occasions. It was not until two days after the fall that staff documented the resident's complaints and ordered an X-ray, which revealed a right hip fracture. The resident was subsequently transferred to a hospital for surgical intervention. The facility's own investigation confirmed that the assigned nurse failed to perform or document a post-fall assessment, did not notify supervisory staff, the physician, or the resident's family, and did not follow established protocols for managing unwitnessed falls and changes in condition. Facility policies required a full post-fall assessment, including neurological checks and range of motion evaluation, before moving a resident after a fall, as well as timely notification of the physician, family, and supervisory staff in the event of a significant change in condition. These procedures were not followed in this case, resulting in a delay in identifying and treating the resident's injury. The deficiency was substantiated through interviews, record reviews, and policy comparisons, which demonstrated a failure to protect the resident from neglect and to ensure their right to be free from abuse and neglect.
Failure to Provide Required Transfer Assistance Resulting in Resident Injury
Penalty
Summary
A resident with a history of cerebrovascular accident, hemiplegia, and recent femur fracture was care planned for total mechanical lift transfers with two staff assistance. The resident was dependent for transfers and required a large sling size, as documented in the care plan and supported by therapy and nursing assessments. On the day of the incident, the resident was transferred by a single CNA without a second staff member, contrary to the care plan and facility policy, which required two-person assistance for mechanical lift transfers. During the transfer, the resident fell, resulting in significant pain and an acute left femoral shaft fracture with intra-articular extension to the knee joint, as confirmed by hospital records and imaging. Multiple interviews and documentation revealed inconsistencies in staff and resident accounts, but it was ultimately determined through investigation and reenactment that the CNA performed the transfer alone. The mechanical lift was present in the room, but the required second staff member was not involved in the transfer process. Facility policies on abuse prevention, safe operation of resident lifts, and fall and injury reduction all required adherence to care plans and manufacturer recommendations, including the use of two staff for mechanical lift transfers when indicated. The failure to follow these protocols and provide the necessary assistance directly resulted in the resident's fall and injury, constituting neglect as defined by facility policy.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours each day, seven days a week, during the period from 4/6/25 to 4/12/25. Review of the staff schedule for 4/5/25 - 4/6/25 showed that all nursing shifts were staffed by Licensed Practical Nurses (LPNs), and the only RN listed had their name crossed out. This indicates that no RN was present on those shifts as required. During an interview, the Director of Nursing (DON) acknowledged that staffing is determined based on census and that there have been instances where staff did not come in as scheduled, often discovered only after the fact. The DON confirmed that the facility is supposed to have an RN on duty and suggested that the RN may have called off, but she was unaware of the specifics as she was out of town at the time. The facility's policy requires daily monitoring and adjustment of staffing to ensure compliance with federal and state requirements, but this was not effectively implemented during the cited period.
Failure to Ensure Competent Nursing Care, Accurate Medication Documentation, and Timely Family Notification
Penalty
Summary
Nursing staff failed to demonstrate appropriate competencies and skills in the care of a resident with significant mobility impairments and a history of cerebrovascular accident, resulting in multiple deficiencies. The resident, who was non-ambulatory and dependent on a mechanical lift with two-person assistance for transfers, sustained a severe left femoral fracture after being transferred by a single CNA without the use of the mechanical lift as required by the care plan. Interviews and documentation revealed that the CNA attempted the transfer alone, contrary to facility policy and the resident's care plan, and the incident was initially misrepresented in statements and reenactments. The resident reported that the mechanical lift was not used, and the CNA confirmed during reenactment that she performed the transfer alone. The nurse on duty did not witness the transfer but confirmed the lift was present in the room and that the resident was lifted from the floor without the mechanical lift after the fall. Additionally, there were significant discrepancies in the documentation of controlled medication administration for the same resident. A review of the Medication Administration Record (MAR) and controlled drug inventory sheets for oxycodone revealed multiple instances where doses were recorded on one document but not the other, as well as inconsistencies in administration times. The Director of Nursing confirmed these discrepancies upon review, which were not in accordance with facility policy requiring immediate and accurate documentation of controlled substance administration on both the MAR and inventory sheets. Furthermore, the facility failed to notify the resident's emergency contact or family member following the resident's transfer to an acute care facility after the fall. Documentation in the medical record and transfer forms did not indicate that the family was notified, and interviews with the resident's family confirmed they were not informed by the facility and only learned of the hospitalization through the resident herself. Facility policy required notification and documentation of such changes in condition, which was not followed in this instance.
Failure to Notify Emergency Contact of Resident Hospitalization
Penalty
Summary
The facility failed to notify the designated emergency contact of a significant change in condition for a resident who experienced a fall resulting in hospitalization. The resident had multiple diagnoses, including a femur fracture, hemiplegia, and other mobility impairments, and was dependent on staff for care. Documentation reviewed, including the SNF/NF to hospital transfer form, SBAR Communication Form, and Progress Notes, did not show evidence that the family member or emergency contact was notified of the resident's transfer to the hospital. Interviews with the resident and her family member confirmed that the family was not informed by the facility and only learned of the hospitalization from the resident herself, after the fact. Staff interviews revealed that while the RN notified the DON and the physician about the resident's change in condition and subsequent transfer, there was no documentation or confirmation that the family was contacted. The DON acknowledged that facility policy requires staff to notify the resident's representative in the event of a significant change and to document this notification in the medical record. A review of the risk event note with the DON confirmed the absence of documentation regarding family notification. The facility's policy also specifies that such notifications and documentation are required.
Failure to Accurately Document and Account for Controlled Substances
Penalty
Summary
The facility failed to maintain accurate accounting and documentation of narcotic medication administration for a resident who was cognitively intact and dependent on staff for transfers following recent leg surgery. The resident was prescribed oxycodone for pain management, with orders changing from 5 mg to 10 mg tablets during the month. Review of the resident's Medication Administration Record (MAR) and Controlled Drug Declining Inventory Sheets revealed multiple discrepancies. Specifically, several doses of oxycodone were documented as administered on the inventory sheets but were not recorded on the MAR, and there were inconsistencies in the times of administration between the two records. The Director of Nursing confirmed these discrepancies upon review, acknowledging that staff are required to document administration in both the electronic record and the inventory sheet at the time of administration. Facility policy mandates immediate and accurate documentation of controlled substances, including date, time, amount administered, and nurse signature, in accordance with federal and state regulations. The observed failures included missing entries and mismatched times between records, resulting in an inability to accurately reconcile the receipt and disposition of controlled drugs for the resident.
Excessive Sanitizer Concentration in Dishwashing Machine
Penalty
Summary
The facility failed to ensure the kitchen dishwashing machine was operating at optimum levels, specifically regarding the concentration of the chemical sanitizer. During an observation on 2/11/2025, it was found that the dishwashing machine's chemical chlorine sanitizer delivery system was excessively concentrated, with levels well over 100 parts per million (ppm), exceeding the required range of 50-100 ppm. Staff A, the Dietary Manager, confirmed this observation after conducting litmus tests that showed a very dark purple color, indicating high concentration levels. Despite this, the machine continued to be used for meal services on 2/11/2025 and 2/12/2025 without corrective action. The issue was compounded by the fact that the facility had previously been cited for a similar violation during a county Department of Health inspection on 1/24/2025, which recommended using manual sanitation until the dish machine was repaired. Although the machine was reportedly repaired two days after the inspection, Staff A was unaware of the overconcentration issue until the surveyor's observation. Additionally, there was no documentation of in-services or education provided to the dietary staff regarding the dishwashing machine's operation since the health department's inspection. Furthermore, Staff A did not have access to the dishwashing machine's operations manual or a policy related to its operating procedure.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to maintain a sanitary and safe environment for residents across two units, as observed over three consecutive days. In one resident's bathroom, a recent wall repair was inadequately covered, leaving a torn panel and missing trash can, while the toilet tank lacked a lid. Another shared bathroom had a rusted glove box holder and a door with peeling paint, creating non-cleanable surfaces. The Director of Maintenance and the housekeeping director were unaware of these issues, indicating a lapse in communication and oversight. Additional observations revealed unsanitary conditions in several rooms, including brown substances around toilet bases, bio-growth on shower chairs and tiles, and missing or malfunctioning fixtures such as light bulbs and toilet paper holders. A room's privacy curtain was stained, and the bathroom had cracked tiles with debris. The Director of Maintenance was not informed of these issues through work orders, and the housekeeping manager was unaware of the stained curtain, suggesting a breakdown in reporting and maintenance processes. Further deficiencies included broken and non-cleanable surfaces in resident rooms, such as a detached handrail, a broken glove box, and an armchair with worn material. The Regional President confirmed these issues during an inspection, noting that repairs and replacements were necessary. The facility's policy mandates a safe and clean environment, yet the observations and interviews indicate a failure to adhere to these standards, as evidenced by the lack of awareness and action from maintenance and housekeeping staff.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure prompt resolution of grievances for two residents, leading to deficiencies in addressing their concerns. Resident #33 reported that their wheelchair was lost during a hurricane evacuation and was not replaced with a suitable one upon return. Despite notifying the Social Service Director (SSD) about the issue, the resident's grievance was not documented in the grievance log, and no resolution was provided, leaving the resident with an ill-fitting wheelchair. Resident #13 expressed concerns about the bearings of their wheelchair, which were causing mobility issues. Although the resident communicated this issue to staff and was offered a new wheelchair, they declined, preferring to have the bearings fixed. The grievance log did not reflect this specific concern, and the Director of Maintenance (DOM) confirmed that no action was taken to order the necessary parts for repair. The SSD acknowledged the unresolved nature of the grievance, indicating a failure to address the resident's specific request.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications across all three units, leading to multiple deficiencies. On the central unit, a medication cart audit revealed expired Sodium Bicarbonate and a dirty cart with debris and packaging materials. Staff H, an LPN, acknowledged the cart's unclean state and the presence of expired medication, attributing the oversight to the night shift's failure to clean and check for expired medications. Similarly, on the north unit, an audit of another medication cart found expired Bisacodyl suppositories, a loose pill, and improper storage of medical gloves with narcotics. Staff E, an RN, confirmed these issues and admitted a lack of awareness regarding proper storage protocols. Additionally, unsecured medications were found in an office on the main unit, accessible to residents, including those with cognitive impairments. The office, belonging to Staff D, an RN, was left unlocked with a box of medications on the floor, posing a risk to residents who frequently passed by. Staff D explained that the medications were meant to be returned to the pharmacy and acknowledged the potential issues arising from the unsecured storage. Furthermore, several residents were observed with medications in their rooms without proper authorization for self-administration. Resident #65 had a cup with multiple pills on their bedside table, and other residents had inhalers and anti-diarrheal medication on their tables. The facility's Director of Nursing confirmed that no residents had orders for self-administration, indicating a failure to adhere to the facility's medication storage policy, which mandates that medications be accessible only to authorized personnel and stored securely.
Inaccurate PASARR Level I Screens for Residents
Penalty
Summary
The facility failed to ensure accurate completion of Preadmission Screening and Resident Review (PASARR) Level I screens for three residents. Resident #64 was admitted with a diagnosis of post-traumatic stress disorder and was prescribed Bupropion for depression. However, the PASARR Level I screen did not indicate any mental illness. The Director of Nursing (DON) confirmed the screen was incorrect and should have been updated. Similarly, Resident #65, who had a diagnosis of depression and was on antidepressant medication, had a PASARR Level I screen that did not reflect this diagnosis. The DON acknowledged that the screen should have been checked and updated upon admission. Resident #40 was admitted with a diagnosis of anxiety disorder, yet their PASARR Level I screen did not indicate this condition. The DON confirmed that the screen should have been updated to reflect the diagnosis. The facility's policy requires that PASARR screenings be conducted prior to admission and reviewed for accuracy, but the Admission Director stated that she did not check for accuracy and had not received training to do so. The DON was responsible for reviewing and updating PASARR screens based on diagnoses and medications, but this process was not adequately followed, leading to the deficiencies identified.
Failure to Implement Contracture Management Care Plan
Penalty
Summary
The facility failed to develop a contracture management splinting care plan with goals and interventions for a resident, leading to a deficiency. The resident, who has a history of muscle wasting, impaired mobility, and a cerebrovascular accident, was observed multiple times without the prescribed right-hand splint/orthotic. Despite the presence of the splint in the resident's room, it was not applied by staff, and there was no documentation of its use in the care plan or medical records. Interviews with the resident revealed that he was aware of the splint and its purpose to alleviate pain, but he was not assisted by staff in wearing it. The resident's right hand showed signs of contracture, and he was observed using his left hand to stretch his contracted fingers. The resident confirmed that staff had previously assisted him with the splint, but it was no longer being applied. Further investigation showed that the occupational therapy staff was responsible for the application of the splint, but there was no documentation to support its consistent use since its delivery. The facility's policy requires that care plans include measurable objectives and interventions to maintain residents' well-being, but this was not adhered to in the case of the resident's contracture management.
Failure to Provide Adequate Nail Care to Resident
Penalty
Summary
The facility failed to provide necessary nail care to a resident who required assistance with activities of daily living (ADL). Observations on two consecutive days revealed that the resident had long, untrimmed fingernails with dark debris underneath, and the resident could not recall when he last received nail care. Despite the resident expressing a desire to have his nails trimmed, there was no documentation of nail care being provided or refused in the resident's records. The resident's care plan indicated a need for assistance with personal hygiene, but there was no specific care plan addressing nail care refusal, despite known refusals since October 2024. Interviews with staff revealed that the Certified Nursing Assistant (CNA) responsible for the resident's care found it challenging to provide nail care due to the resident's refusals. The Director of Nursing (DON) acknowledged that refusals should be documented and care planned, but there was no evidence of such documentation or care planning. The facility's policies required CNAs to provide nail care during showers and document any refusals, but there was a lack of consistent documentation and follow-up. The Social Services Director confirmed that grievances had been filed regarding the resident's nail care, and although some resolutions were attempted, the issue persisted without a proper care plan in place. The facility lacked an ADL policy, relying instead on care plans that were not adequately updated to reflect the resident's needs and refusals.
Failure to Administer Enteral Nutrition as Ordered
Penalty
Summary
The facility failed to provide enteral nutrition per physician orders for a resident with enteral nutrition orders. The resident, who had a medical history including malignant neoplasm of the larynx and chronic obstructive pulmonary disease, was observed multiple times with the enteral feeding pump not running, despite having an order for continuous feeding at 65 ml/hr. Observations over several days showed that the enteral feeding pump was often off, and the feeding formula was not being administered as prescribed. The resident reported that the pump had not been running, and the observations confirmed that the feeding was not being delivered as ordered. Interviews with staff revealed that the registered nurse was aware of the order for continuous feeding but had not ensured the feeding was administered as prescribed. The registered dietitian expressed concern about the missed nutrition, and the Director of Nursing acknowledged the need to investigate the handling of the resident's orders. The facility's policy emphasized optimizing nutritional status in accordance with the resident's wishes, but the lack of adherence to the physician's orders resulted in a deficiency in care for the resident.
Failure to Implement Pharmacy Recommendations for Two Residents
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were implemented for two residents, leading to deficiencies in medication management. Resident #64, who was admitted with chronic obstructive pulmonary disease (COPD), had a physician's order for Breo Ellipta Inhalation Aerosol. The consultant pharmacist recommended adding a reminder to rinse the mouth after using the inhaler to prevent oral thrush, but this recommendation was not signed, reviewed, or completed. As of February 11, 2025, the physician's order had not been updated to include the recommended verbiage. Resident #2, admitted with multiple diagnoses including COPD, epilepsy, and major depressive disorder, had several pharmacy recommendations that were not addressed. The consultant pharmacist suggested clarifying and updating medication orders and evaluating the use of certain medications due to their potential to cause falls. Despite these recommendations, the physician's orders remained unchanged as of February 12, 2025. The Director of Nursing confirmed that the pharmacy recommendations for both residents had not been addressed and should have been referred to the physician for follow-up. The facility also failed to provide the requested policy and procedure for pharmacy recommendations.
Medication Administration Errors Lead to 10% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 10% error rate during the survey. Three medication errors were identified involving three residents. For Resident #32, a Licensed Practical Nurse (LPN) administered Cetirizine HCL instead of the prescribed Claritin. The LPN acknowledged the error, noting that the medications were stored close together in the cart, leading to the mistake. Resident #36 did not receive their prescribed Entresto due to it not being available in the medication cart. The medication had not been reordered in time, and there was no documentation that the physician was notified of the missed dose. Interviews with the facility's pharmacy and the resident's primary care physician confirmed the lack of communication regarding the missed medication. For Resident #11, an LPN administered 1.5 ml of Risperidone instead of the prescribed 1.0 ml for the morning dose. The error occurred because the electronic charting system displayed the bedtime dosage alongside the morning order, leading to confusion. The Director of Nursing reviewed the orders and acknowledged the potential for error due to the system's display issue.
Inadequate Infection Control for Scabies Case
Penalty
Summary
The facility failed to ensure proper infection control practices for a resident diagnosed with scabies. The resident, who was cognitively intact, reported itching and had visible scabbed spots on her legs. Despite being prescribed Permethrin cream for scabies, the medication was not administered as ordered, and the resident continued to experience symptoms. The facility's records showed inconsistencies in the administration of Ivermectin, with several doses marked as not given or awaiting pharmacy delivery. Interviews with staff revealed a lack of awareness and communication regarding the resident's scabies diagnosis. The LPN responsible for the resident was unaware of the scabies treatment, and the RN/Unit Manager did not recognize the need for isolation or room cleaning. The Director of Nursing and the Nursing Home Administrator were also unaware of the scabies case, indicating a breakdown in communication and adherence to the facility's scabies management policy. The facility's policy required contact precautions, isolation, and thorough cleaning of the resident's room, none of which were implemented. The Housekeeping Manager confirmed that no special cleaning requests were made for the resident's room. The failure to follow the facility's scabies management policy and ensure proper medication administration led to the deficiency in infection control practices.
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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