Space Coast Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Merritt Island, Florida.
- Location
- 125 Alma Blvd, Merritt Island, Florida 32953
- CMS Provider Number
- 105325
- Inspections on file
- 31
- Latest survey
- August 2, 2025
- Citations (last 12 mo.)
- 6 (3 serious)
Citation history
Health deficiencies cited at Space Coast Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Nurses and nurse aides lacked the necessary competencies to provide care that maximizes each resident's well-being. Staff were not adequately prepared to meet the individualized needs of residents, resulting in care that did not support their highest practicable level of well-being.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action, resulting in a lack of systematic review and response to quality issues.
The facility failed to manage and provide access to residents' personal funds, affecting two residents. One resident, despite having a significant account balance, faced repeated denials when accessing funds for necessary purchases. Another resident discovered a negative balance in her account, which was withheld to cover the deficit without her consent. The facility's transition to a new company caused delays and cash shortages, violating their policy of providing cash within one day of request.
The facility failed to create a homelike dining environment for residents in the B Wing dining room. Observations revealed that tables lacked tablecloths, centerpieces, and decorations, and the room was silent without music. Meals were served on trays, which were not removed or arranged on the tables, and staff left the room after serving. A CNA and the Administrator acknowledged the lack of a homelike atmosphere.
The facility failed to dispose of waste properly due to a damaged dumpster with missing and warped lids, which was observed during a kitchen inspection. The dumpster, in disrepair for about two months, contained garbage bags with food items and adult briefs, with one bag torn open. The Certified Dietary Manager and Maintenance Director acknowledged the issue, but the Administrator was unaware until the survey. The facility continued using the dumpster despite its condition, violating the FDA's 2017 Food Code requirement for tight-fitting lids.
The facility's QAPI committee failed to sustain improvements, resulting in repeat deficiencies at F584, F585, F694, and F814. Despite monthly meetings and data reviews, insufficient auditing and oversight led to noncompliance. The Administrator acknowledged a system breakdown in sustaining improvements.
The facility failed to ensure proper infection control measures by not having correct signage and readily available PPE for residents on Enhanced Barrier Precautions (EBP). Observations showed incorrect or missing EBP signage and PPE stored away from resident rooms. Additionally, resident equipment was improperly stored, with unlabeled basins found on the bathroom floor, breaching infection control protocols.
Two residents with severe cognitive impairment experienced a lack of dignity during dining. One resident had to lick dessert from containers due to inappropriate utensils, while another waited 45 minutes for lunch due to kitchen delays and staff oversight. The DON acknowledged the need for timely meal service and staff presence.
Two residents were found self-administering medications without proper evaluation or physician orders. One resident used nasal spray, while another took Vitamin B-12 and had an empty Rosuvastatin container. Both had intact cognition, but their clinical records lacked necessary assessments and orders. An LPN confirmed the oversight, and the DON acknowledged the deficiency, which violated the facility's policy requiring interdisciplinary assessment and physician orders for self-administration.
A HIPAA violation occurred when a computer screen on a medication cart was left unlocked, exposing a resident's medical information to passersby. The ADON admitted to leaving the screen open after checking the resident's name, contrary to the facility's policy requiring staff to lock computers when not in use.
A resident reported a missing cell phone, but the facility failed to document the grievance or resolve the issue promptly. Despite informing staff, the grievance was not logged, and the resident had to buy a new phone, impacting her communication with family. The Social Services Director and Unit Manager were aware but did not follow the grievance process.
The facility failed to provide adequate grooming and hygiene care for three residents, resulting in deficiencies in their ADL care. A resident with severe cognitive impairment was observed with long, dirty nails, while another had long facial hair on her chin. A third resident, with moderately impaired cognition, had untrimmed nails with a dark substance underneath. Staff acknowledged the oversight, despite facility policies requiring regular grooming and hygiene maintenance.
The facility failed to provide an ongoing program of activities for three residents, who were observed without engaging in any activities despite their care plans indicating preferences for music, social activities, and outdoor time. The Activity Director's documentation did not reflect any actual activities being provided, highlighting a deficiency in meeting the residents' needs.
A resident with diabetes and glaucoma experienced a delay in receiving necessary eye care due to the facility's failure to follow up on multiple orders for a retinal consult. The resident's optometrist had noted bleeding behind the eye, requiring specialist attention, but the facility's scheduling process missed the orders due to incorrect entry as prescriber written instead of verbal or telephone orders. This led to a significant delay in treatment.
A facility failed to change a resident's IV dressing as scheduled, leading to a potential 10-day gap without a change. The resident, with a history of MRSA and a current wound infection, was receiving IV antibiotics. The MAR lacked documentation for a dressing change on a specific date, and the DON confirmed the oversight. The RNC identified an issue with the as-needed order setup, preventing proper documentation.
The facility failed to implement pharmacy recommendations and physician orders for three residents, leading to deficiencies in medication management. A resident had multiple unaddressed pharmacist recommendations, including dose reductions and medication discontinuations. Another resident's medication adjustments to reduce fall risk were not implemented, and a third resident's agreed-upon changes for Psyllium and insulin were not reflected in their orders. The DON acknowledged issues with the MRR process, including lack of rationale for physician disagreements.
A facility failed to limit a PRN order for Xanax to 14 days for a resident with schizophrenia, psychosis, dementia, depression, seizures, and chronic kidney disease. The order, dated without a stop date, was not re-evaluated as required. Interviews with staff revealed that PRN Xanax is typically prescribed for 14 days, and the facility's policy lacked a stop date protocol for PRN psychotropic medications.
A facility failed to prevent a mentally impaired resident from exiting unsupervised, despite being identified as an elopement risk. The resident left through a window with a broken latch and was found walking on a busy road without shoes. Staff failed to secure the window and did not increase supervision despite the resident's history and recent behavioral changes.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Inadequate Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified based on observations and findings that staff lacked appropriate skills or knowledge required to meet the individualized needs of residents. This failure resulted in care that did not support the highest practicable level of physical, mental, and psychosocial well-being for residents. The report specifically notes that staff were not adequately prepared to address the unique care requirements of all residents, which directly impacted the quality of care provided.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's actions or inactions regarding the required reporting process for such incidents. The report indicates that there was a delay or failure in notifying the appropriate authorities about the suspected event and in communicating the outcomes of the internal investigation as required by regulations.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process for identifying, reviewing, and addressing quality issues within the facility. As a result, there was no documented evidence that quality deficiencies were being regularly reviewed or that corrective plans were being developed and implemented to address identified issues.
Deficiency in Managing Resident Funds
Penalty
Summary
The facility failed to properly manage and provide access to residents' personal funds, affecting two residents. Resident #32, who is cognitively intact, reported difficulties accessing his money for necessary purchases like phone cards. Despite having a significant balance in his account, he was repeatedly told that funds were unavailable, and he had not received his quarterly statements for at least six months. A grievance filed by him earlier in the year highlighted similar issues, but there was no evidence of resolution communicated to him. Resident #47, also cognitively intact, experienced a negative balance in her account, which she was unaware of until informed by the facility. She was accustomed to receiving regular cash withdrawals but was told her account was overdrawn by approximately $400. The facility continued to withhold her monthly allowance to cover this negative balance without obtaining her consent or signature. The Business Office Manager acknowledged the billing error and the lack of proper communication with the residents regarding their account statuses. The Business Office Manager explained that the facility's transition to a new company for handling checks had caused delays and cash shortages, particularly during high-demand periods like holidays. The facility's policy required cash to be available within one day of request, but this was not consistently met. The Activities Director confirmed delays in purchasing items for residents due to these financial management issues. The facility's failure to adhere to its own policies and ensure residents' access to their funds led to significant dissatisfaction and financial inconvenience for the residents involved.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike environment for residents dining in the B Wing dining room, as observed during meal times. On two separate occasions, residents were seen eating their meals in a setting that lacked homelike features. The tables were devoid of tablecloths or centerpieces, and the walls were bare without any pictures or posters. Additionally, there was no music playing, resulting in a very quiet atmosphere. Residents were served their meals on trays, which were not removed or arranged on the tables, and staff left the room after serving the trays. A Certified Nursing Assistant (CNA) confirmed that meals were delivered on a cart full of trays and served to residents in this manner. The CNA also acknowledged the absence of tablecloths and the usual silence in the room. The facility's Administrator later observed the dining room and admitted that it was not homelike and required improvement. The facility's policy on providing a safe, clean, and comfortable homelike environment was not adhered to, as evidenced by the observations and staff acknowledgments.
Improper Waste Disposal Due to Damaged Dumpster
Penalty
Summary
The facility failed to ensure waste was disposed of in a sanitary manner, as observed during a kitchen inspection. An uncovered dumpster was found at the back of the facility, with one lid missing and the other lid warped and half torn from the hinge, preventing it from sealing properly. This condition was acknowledged by the Certified Dietary Manager, who stated that the maintenance department was responsible for maintaining the dumpsters. The Maintenance Director confirmed the dumpster's condition, noting it had been like this for about two months and that the regional maintenance consultant was aware of the need for replacement. The Administrator was not informed of the dumpster's disrepair until the survey, and despite acknowledging the issue, the facility continued to use the dumpster due to a lack of alternatives. Observations revealed garbage bags containing food items, drink cans, plastic utensils, paper products, and adult briefs, with one bag torn open. The Food and Drug Administration's 2017 Food Code requires outside receptacles for waste to have tight-fitting lids, which the facility failed to comply with, potentially attracting pests and rodents.
Repeat Deficiencies in QAPI Activities
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee conducted effective performance improvement activities to sustain prior improvement measures. The facility had previously been cited for deficiencies at F584, F585, F694, and F814 during a recertification survey conducted in May 2023. However, during the current survey, the facility was found to be in noncompliance with the same deficiencies, indicating that the corrective measures were not sustained. The QAPI program was intended to be comprehensive and data-driven, focusing on indicators of care outcomes and quality of life, but it was identified that there was insufficient auditing and oversight to correct the deficiencies. The Administrator acknowledged that the QAPI committee met monthly and included staff from various departments to review and discuss data gathered by departments. Performance Improvement Plans (PIPs) were developed and implemented based on survey outcomes, and audits were part of PIP monitoring. Despite these efforts, the Administrator admitted that repeat citations were identified during the current survey, indicating a system breakdown that needed to be addressed. The goal of the QAPI activities was to make and sustain improvements, but the repeat deficiencies highlighted a failure in achieving this objective.
Inadequate Infection Control and Equipment Storage
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, specifically regarding Enhanced Barrier Precautions (EBP) and the storage of resident equipment. Observations revealed that signage for EBP was incorrect or missing, and Personal Protective Equipment (PPE) was not readily available for residents on EBP. For instance, a resident on contact isolation due to a wound had incorrect signage and lacked appropriate PPE outside the room. The Infection Preventionist acknowledged these issues, noting that PPE was stored in a supply room rather than being accessible at the point of care. Additionally, another resident receiving gastrostomy tube feeding had no EBP signage or PPE available, highlighting a systemic issue in the facility's infection control practices. Furthermore, the facility did not adhere to proper storage protocols for resident equipment, as evidenced by the observation of unlabeled basins on the bathroom floor in a resident's room. These basins were not stored in plastic bags or labeled with the resident's name, which the Infection Preventionist and staff acknowledged as a breach of infection control practices. The facility's policy did not address the storage of resident equipment, contributing to the deficiency in maintaining sanitary conditions.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to maintain the dignity of two residents during dining. Resident #13, who has severe cognitive impairment and is dependent on assistance for all activities of daily living, was observed eating dessert by licking pudding and a frozen treat directly from the containers. This occurred because the built-up spoon provided was too large to fit into the dessert cups. No staff were present in the dining room to assist or observe the resident during this time. Resident #88, also with severe cognitive impairment, was left waiting for her lunch for 45 minutes while sitting at a table with another resident who was eating. A CNA mistakenly thought Resident #88 had already eaten and only realized the error after being informed. The delay was due to the kitchen running out of food and having issues with the oven, which resulted in a second portion of meals needing to be cooked. The Director of Nursing acknowledged that residents should receive their meals at approximately the same time and that staff should be present to observe residents while dining.
Failure to Evaluate and Document Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents were properly evaluated for the safe self-administration of medications and did not obtain the necessary physician orders for self-administration. Resident #37, a female with intact cognition, was observed with a bottle of nasal spray on her tray table, which she self-administered. Despite her claim of being tested for competency, there was no documented assessment or physician's order for the nasal spray or for self-administration in her clinical records. Licensed Practical Nurse (LPN) A confirmed the absence of such documentation and acknowledged that the nasal spray should have been kept on the medication cart. Resident #95, also with intact cognition, was found with Vitamin B-12 and an empty container of Rosuvastatin in her bedside drawer. She self-administered the Vitamin B-12 daily but was unsure if the nurses were aware of it. A review of her clinical records revealed no physician's order or assessment for self-administration of the Vitamin B-12. LPN A stated that all medications, including over-the-counter ones like Vitamin B-12, should have a physician's order to prevent drug interactions and should be documented by the nursing staff. The Director of Nursing (DON) was informed of the findings, including the lack of physician orders and assessments for self-administration for both residents. The facility's policy requires an interdisciplinary team to assess the safety of self-administration and obtain a physician's order before allowing residents to self-administer medications. However, this protocol was not followed for the two residents, leading to the deficiency.
HIPAA Violation Due to Unlocked Computer Screen
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's medical records, resulting in a Health Insurance Portability and Accountability Act (HIPAA) violation. On January 16, 2025, at 10:20 AM, a computer on medication cart #1, located near the nurses' station on the A Wing, was observed with its screen open and facing the hallway. This allowed pertinent information regarding a resident to be visible to staff, residents, and visitors passing by. At 10:24 AM, RN F was present at the medication cart and stated that she had previously locked the computer screen before leaving the cart. However, at 10:29 AM, the Assistant Director of Nursing (ADON) confirmed that she had logged onto the computer to check the spelling of the resident's name and forgot to lock the screen when she walked away. The ADON acknowledged that this oversight constituted a HIPAA violation. The facility's policy, effective April 1, 2022, and revised on February 21, 2023, mandates that staff lock or log off computers when not in use to protect residents' personal health information.
Failure to Follow Grievance Process for Missing Personal Property
Penalty
Summary
The facility failed to adhere to its grievance process, resulting in a deficiency related to a resident's missing personal property. A resident, who was cognitively intact, reported losing her cell phone in her previous room. Despite informing staff and the Social Services Director about the missing phone, the facility did not document the grievance or make prompt efforts to resolve it. The resident had to purchase a new phone, which she could hardly afford, and was unable to communicate with her daughter for almost a month due to the missing phone. The Social Services Director, who was also the Grievance Officer, confirmed that grievance forms were available and that grievances were discussed in management meetings. However, the resident's grievance was not documented in the Grievance Log, and the Social Services Director only planned to write a grievance form after the resident provided a receipt for the new phone. The Social Services Director acknowledged that staff were expected to inform her of grievances, but this did not occur in this case. The B-Wing Unit Manager and a CNA were aware of the missing phone and had searched for it, but it was not found. The Unit Manager collected a witness statement from the CNA but did not complete a grievance form, assuming the Social Services Director would handle it. The facility's policy required grievances to be documented and tracked, but this process was not followed, leading to the deficiency.
Deficiencies in Resident Grooming and Hygiene Care
Penalty
Summary
The facility failed to provide adequate nail care and removal of chin hair for three residents, leading to deficiencies in their activities of daily living (ADL) care. Resident #13, who was severely cognitively impaired and dependent on staff for all ADLs, was observed with long, dirty nails while eating lunch. Despite having a care plan that directed staff to check and clean nails on bath days and as necessary, the resident's nails were neglected. RN I acknowledged the oversight, stating that CNAs were aware of their responsibility to maintain nail hygiene daily. Resident #88, also severely cognitively impaired and requiring substantial assistance with personal hygiene, was observed with long facial hair on her chin over several days. RN I confirmed that CNAs were expected to remove facial hair on shower days or when noticed, and the resident did not refuse care. Similarly, Resident #87, with moderately impaired cognition and dependent on staff for personal hygiene, was found with untrimmed nails and a dark substance underneath. CNA C admitted to not providing nail care despite the resident being in her assignment. The facility's policy required CNAs to maintain residents' grooming and hygiene, which was not adhered to in these cases.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the needs and preferences of three residents, as observed during a survey. Resident #13, who has severe cognitive impairment due to dementia and other conditions, was frequently observed in the day room or in her room without engaging in any activities, despite her care plan indicating a preference for music, going outside, and group activities. There was no documentation from the Activity staff indicating that activities were offered or declined by the resident. Resident #40, with moderate cognitive impairment and other health issues, was also observed lying in bed with no activities or television on, despite his care plan noting a preference for reading, music, and social activities. Similar to Resident #13, there was no documentation from the Activity staff about offering activities or the resident declining them. Resident #88, who has severe cognitive impairment and requires assistance with personal care, was observed multiple times in the day room and in her room without engaging in any activities. Her care plan indicated a preference for being outside, group activities, and music. The Activity Director acknowledged that activities were primarily conducted in the main dining room and that residents who self-isolated typically did not participate. The documentation provided by the Activity Director did not reflect any actual activities being provided to the residents, indicating a deficiency in meeting the residents' activity needs.
Failure to Ensure Timely Vision Care for Resident
Penalty
Summary
The facility failed to ensure a resident received timely treatment to maintain his vision, specifically for a resident with a history of type 2 diabetes, bilateral leg amputation above the knee, and glaucoma. The resident was cognitively intact and had been informed by his optometrist of bleeding behind his left eye, necessitating a specialist consultation. Despite multiple notes and orders from the optometrist and physician to arrange a retinal consult, the facility did not follow up in a timely manner. The resident eventually saw a specialist, but the delay in consultation may have impacted the effectiveness of the treatment. The deficiency was attributed to a breakdown in the facility's process for scheduling external appointments. The transportation and scheduler for residents' appointments explained that orders needed to be entered as verbal or telephone orders to appear on her report. However, several orders for the resident's retinal consult were entered as prescriber written, causing them to be missed in the scheduling process. This oversight was compounded by the expiration of a verbal order before it was acted upon. The facility's failure to ensure proper communication and follow-up resulted in a significant delay in the resident receiving necessary eye care.
Failure to Timely Change IV Dressing for Resident
Penalty
Summary
The facility failed to ensure the timely and appropriate administration of IV dressing changes for a resident receiving IV therapy. The resident, who was admitted with a history of MRSA infection and a current diagnosis of wound infection, was receiving IV antibiotics. The care plan required regular observation and changing of the IV dressing per physician orders and facility protocol. However, the Medication Administration Record (MAR) showed a lapse in documentation and execution of the dressing change schedule. Specifically, the dressing was changed on 1/03/25, but there was no documentation of a change on 1/10/25, and the next scheduled change was set for 1/17/25, indicating a potential 10-day gap without a dressing change. Observations and interviews revealed that the IV dressing was dated 1/07/25, and the Licensed Practical Nurse (LPN) confirmed that the dressing should have been changed on 1/14/25. The Director of Nursing (DON) acknowledged the oversight and the lack of documentation for an as-needed dressing change on 1/07/25. The Regional Nurse Consultant (RNC) identified an issue with the setup of the as-needed order, which prevented proper documentation of dressing changes. This deficiency in the facility's protocol and documentation process led to a failure in maintaining the resident's IV site as per the required schedule.
Failure to Implement Pharmacy Recommendations and Physician Orders
Penalty
Summary
The facility failed to implement pharmacy recommendations and physician orders, and did not document a physician rationale for not following pharmacy recommendations for three residents. Resident #61 had multiple medication regimen review (MRR) recommendations from the pharmacist that were either not responded to by the physician or agreed upon but not implemented. These included recommendations for dose reductions, discontinuations, and medication switches due to potential risks such as increased falls and improper medication administration. Despite the physician's agreement on some recommendations, changes were not reflected in the medical record, and no rationale was provided for disagreements. Resident #34, who was cognitively intact and had a history of falls, received several MRR recommendations from the pharmacist regarding medication adjustments to reduce fall risk and manage diabetes. The physician disagreed with all recommendations without providing a rationale in the medical record or the MRR report. This lack of documentation and implementation of pharmacy recommendations contributed to the deficiency. Resident #11's MRR included recommendations for proper administration instructions for Psyllium and evaluation of the need for sliding scale insulin. Although the physician agreed to these recommendations, the changes were not implemented in the resident's orders. The Director of Nursing acknowledged the issues with the MRR process, including the lack of rationale for physician disagreements and the failure to implement agreed-upon changes, which were attributed to high turnover among Unit Managers and the handling of the process by the Assistant DON and herself.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that a PRN order for a psychotropic drug, specifically Xanax, was limited to fourteen days for a resident. The resident, a male with a history of schizophrenia, psychosis, dementia, depression, seizures, and chronic kidney disease, had a physician order dated October 1, 2024, for Xanax 1 mg every 12 hours as needed for agitation. This order did not include a stop date, which is a requirement for PRN psychotropic medications. The facility's Director of Nursing (DON) acknowledged the absence of a stop date and stated that the medication should have been re-evaluated for continuation. Interviews with the A Wing Registered Nurse/Unit Manager and the DON revealed that PRN Xanax is typically prescribed for 14 days, and if used occasionally, it could be continued for 30 days. However, if not used, the medication should be discontinued. The facility's policy on administering medications did not address a stop date protocol for PRN psychotropic medications, but it did instruct that frequent PRN use should prompt a reevaluation by the Attending Physician and the Interdisciplinary Care Team. Despite these guidelines, the resident's medical record lacked documentation of a stop date or reevaluation for the Xanax prescription.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent a mentally impaired resident from exiting the facility unsupervised and did not provide adequate supervision and a secure environment. The resident, who had severe cognitive impairment and a history of elopement, was able to leave the facility through a window. The resident's medical record indicated he had multiple diagnoses, including osteomyelitis, type 2 diabetes with foot ulcer, cognitive communication deficit, and schizoaffective disorder. Despite being identified as an elopement risk and having an elopement alarm, the resident managed to exit the facility unsupervised. On the day of the incident, staff discovered the resident was missing and initiated a search. The resident was found walking on a busy road without shoes, wearing only non-skid socks. Interviews with staff revealed that the resident had been transferred to a new room the day before the elopement, and the window in this new room was not checked or secured. The Maintenance Director admitted that checking windows was not part of his daily inspections, and the window latch in the resident's new room was broken. The facility's policy on elopement and missing residents emphasized maintaining a safe and secure environment, but this was not effectively implemented. The staff failed to notice an increase in the resident's behaviors and did not increase supervision accordingly. The Administrator and DON acknowledged that the root cause of the incident was the failure to secure the resident's window and to recognize the need for increased supervision. The facility's assessment tool indicated that they were equipped to handle residents with psychiatric and cognitive impairments, but this incident demonstrated a lapse in ensuring the safety of such residents.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
