Spring Lake Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Winter Haven, Florida.
- Location
- 1540 6th St Nw, Winter Haven, Florida 33881
- CMS Provider Number
- 105730
- Inspections on file
- 17
- Latest survey
- February 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Spring Lake Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to conduct accurate PASRR screenings for residents with mental disorders, leading to missed Level II evaluations. A resident was readmitted without mental health diagnoses, despite using psychotropic medication. Another resident with PTSD was not referred for Level II screening, and a third resident's PASRR did not reflect all mental health diagnoses. The facility did not follow its policy to notify state authorities of significant changes in residents' mental conditions.
The facility failed to post appropriate oxygen use signage in 23 resident rooms where oxygen was administered. Observations revealed the absence of such signs, despite the presence of no smoking signs outside the facility and on oxygen storage rooms. Interviews with facility leadership indicated a misunderstanding regarding the necessity of additional signage, and the facility lacked a specific policy on oxygen signage.
A resident was not adequately informed or encouraged to participate in activities, despite expressing interest and having a care plan that required such interventions. Additionally, the facility failed to coordinate communication for another resident and did not post necessary safety signs in rooms where procedures were administered. The facility lacked a policy for signage, impacting safety standards.
A resident with dementia and other health conditions was observed eating lunch with his fingers in a high-traffic hallway, assisted by staff standing over him. The resident was placed there for monitoring, as requested by his daughter, but the DON acknowledged this could be a dignity concern. The facility lacked a policy on dignified dining.
The facility did not ensure timely submission of MDS assessments for two residents. A resident's death assessment was completed but not submitted, and another resident's discharge assessment was delayed. Staff attributed the issue to a switch in electronic medical records systems.
A resident expressed willingness to participate in activities if invited, but the facility failed to inform or encourage them, resulting in minimal engagement. The resident's care plan required invitations and assistance for activities, yet documentation showed limited participation. The Activity Director acknowledged documentation gaps, and the facility's policy on individual activities was not effectively implemented.
A facility failed to coordinate communication with a dialysis center for a resident with end-stage renal disease. Despite providing transportation, the facility did not ensure the completion of communication forms from the dialysis center, which are crucial for documenting treatment details. Staff interviews revealed a lack of policy and difficulties in obtaining necessary information, leading to incomplete documentation and inadequate collaboration as required by the contract.
The facility failed to securely store medications, leaving them accessible to unauthorized individuals. On the 800-hall, a thermal cooler with Lacto Probiotic was left unattended on a medication cart. On the 200-hall, a medication cart was left unlocked and out of view while insulin was administered to a resident, contrary to facility policy.
A facility failed to initiate timely Enhanced Barrier Precautions (EBP) for a resident with surgical wounds admitted for rehabilitation. Despite the facility's policy requiring EBP for residents with wounds, the resident did not have any signage indicating EBP. Interviews with the ADON/ICP and DON confirmed the oversight, with the DON citing high turnover as a contributing factor.
A resident was observed eating lunch in a high-traffic hallway while seated in a wheelchair, with staff assisting him in a manner that raised dignity concerns. The resident required assistance with personal care, and staff placed him in the hallway for monitoring. The DON acknowledged the potential dignity issue, and the facility lacked a policy on dignified dining.
A survey found that a delayed egress exit door in the main dining room of a facility failed to close and latch properly, as required by NFPA 101. The maintenance director acknowledged the issue, which was observed during a facility tour. This deficiency highlights a lapse in maintaining functional egress systems for safety.
The facility failed to maintain smoke barrier integrity as required by NFPA 101. During a tour, an unsealed penetration and untested blowout patching were observed above the smoke door and ceiling by room 106. The maintenance director acknowledged these issues, noting that the barrier was not sealed to the deck.
An oxygen concentrator in the rehab area was found with an outdated PCREE certification from July 2021, indicating non-compliance with NFPA 99 standards. The maintenance director confirmed the concentrator was provided by a rental company, suggesting a lapse in oversight of equipment maintenance and certification.
Failure to Conduct Accurate PASRR Screenings
Penalty
Summary
The facility failed to obtain an accurate Pre-Admission Screening and Resident Review (PASRR) for a resident prior to their re-admission. The resident was initially admitted and later readmitted without any mental health diagnoses recorded. However, the resident's medication administration record indicated the use of psychotropic medication for anxiety, and the care plan noted a risk for adverse reactions related to psychotropic medication use. An updated Level I PASRR later revealed diagnoses of anxiety disorder, depressive disorder, adjustment disorder, and a history of PTSD, but still concluded that a Level II PASRR was not required. Additionally, the facility did not ensure that residents with mental illness or suspected mental illness were referred for Level II screening. One resident had a Level I PASRR that did not indicate a need for Level II screening despite having a diagnosis of PTSD and experiencing related symptoms such as nightmares and anxiety. The Director of Nursing stated that the resident did not qualify for a Level II PASRR because they were stable and did not exhibit behaviors. Another resident's Level I PASRR indicated anxiety disorder but did not check depressive disorder, despite the resident having diagnoses of anxiety, major depressive disorder, and adjustment disorder. The Director of Nursing stated that a Level II screen was not needed because the resident's dementia diagnosis was not primary or secondary. The facility's policy requires notification to the state mental health authority for significant changes in residents with mental disorders, but this was not adhered to in these cases.
Plan Of Correction
1. Resident #98's PASRR has been updated to accurately reflect the physical and mental condition of the resident. Resident #15 has been discharged from the facility. Resident #96 has been referred for a Level II PASRR. 2. Director Of Nursing/Social Services Director/Designee have completed a review of current facility residents to verify PASRR accurately reflects the resident and has been submitted for a Level II review if indicated. Follow up based on findings. 3. Staff Development Coordinator/Designee has provided education for Inter Disciplinary Team related to PASRR requirements. 4. Director Of Nursing/Social Services Director/Designee to complete monitoring of admission and readmission residents using the morning meeting process to verify PASRR accuracy and has been referred for a Level II if applicable for a period of 3 months, then quarterly as needed or until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Committee Meeting. Modifications implemented as indicated.
Failure to Post Oxygen Use Signage in Resident Rooms
Penalty
Summary
The facility failed to ensure appropriate cautionary and safety signs indicating the use of oxygen were posted in 23 out of 23 randomly observed rooms where oxygen was administered. During observations on two separate days, it was noted that there were no oxygen use signs near the resident rooms, although no smoking signs were posted outside the facility and on the oxygen storage rooms. Interviews with the Nursing Home Administrator, the Director of Nursing, and the President of Clinical Services revealed a misunderstanding that no additional oxygen signage was necessary due to the existing no smoking signs. The facility lacked a specific oxygen policy related to the posting of oxygen signs.
Plan Of Correction
1. Signage was updated to reflect use inside the facility. 2. Administrator/Designee completed observation of facility entrances to verify signage stating usage is present. 3. Regional Support Team member provided education for the facility Inter Disciplinary Team related to signage posting requirements. 4. Administrator/Designee will observe the facility entrances to verify in use signage in place weekly x 4, then as needed until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Committee Meeting. Modifications implemented as indicated.
Deficiencies in Resident Activities and Safety Signage
Penalty
Summary
The facility failed to provide adequate and appropriate health care by not assisting and providing activities per preference to a resident. The resident expressed a willingness to participate in activities but was not informed or invited by the staff. Observations revealed that the activity calendar was placed too high for the resident to see, and there was a lack of documentation regarding the resident's participation in activities. The resident's care plan indicated a need for encouragement and assistance to attend activities, but these interventions were not effectively implemented. Additionally, the facility failed to coordinate communication with a center for another resident. There was a lack of documented evidence of collaboration of care and communication between the nursing facility and the unit. This included participation in care conferences and the review of control policies and procedures, which are essential for ensuring comprehensive care for the resident. Furthermore, the facility did not ensure appropriate cautionary and safety signs were posted in 23 randomly observed rooms where certain procedures were administered. Despite having no smoking signs outside the facility, there were no specific signs indicating the use of certain procedures inside the facility. The facility lacked a policy related to the posting of these signs, which is necessary for maintaining safety standards.
Plan Of Correction
Preparation and/or execution of this Plan of Correction does not constitute admission or agreement by the provider of the truth of the items alleged or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by the provision of Federal and State Laws, code section 1280 and 42 CFR 483.1. 1. Resident #71 has been discharged from the facility. Resident #36 has been discharged from the facility. Signage was updated to reflect use inside the facility. 2. Activities Director/Designee has completed a review of current facility residents to confirm that activities are provided per preference. Director of Nursing/Designee has conducted a review of current facility residents to verify communication is completed as required. Follow up based on findings. Administrator/Designee completed observation of facility entrances to verify signage stating usage is present. 3. Staff Development Coordinator/Designee has provided education to activity staff related to assisting and providing resident's preferred activities. Staff Development Coordinator/Designee has completed education for current facility licensed nurses related to communication requirements. Regional Support Team member provided education for the facility Inter Disciplinary Team related to signage posting requirements. 4. Activities Director/Designee to monitor residents to verify that activities are provided per preference using a random sample of 10 residents weekly x 3 months then as needed until substantial compliance is achieved. Director of Nursing/Staff Development Coordinator/Unit Manager/Designee to complete monitoring of residents to verify communication documentation is present weekly x 3 months, then as needed until substantial compliance is achieved. Administrator/Designee observed the facility entrances to verify in use signage in place weekly x 4, then as needed until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Committee Meeting. Modifications implemented as indicated.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident, who was observed eating lunch with his fingers while seated in a high-traffic hallway. Two staff members were seen adjusting the resident in his wheelchair, with one assisting him with his meal while standing over him. The resident, who has diagnoses including type 2 diabetes mellitus, dementia, and anxiety, requires assistance with personal care. Interviews with staff revealed that the resident is placed in the hallway during meals for monitoring purposes, as requested by his daughter, but the Director of Nursing acknowledged that this arrangement could be a dignity concern. The facility lacked a policy related to dignified dining.
Plan Of Correction
Preparation and/or execution of this Plan of Correction does not constitute admission or agreement by the provider of the truth of the items alleged or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by the provision of Federal and State Laws code section 1280 and 42 CFR 483.1. 1. Resident #7's plan of care has been updated to reflect the dining preferences of the resident/resident representative. The resident's representative has received information specific to dignified dining, who verbalized understanding. 2. Director of Nursing (DON)/Designee has completed observation of current facility residents while dining to verify dignity is maintained. Follow up based on findings. 3. Staff Development Coordinator (SDC)/Designee has completed education for current facility employees related to maintaining resident dignity while dining. 4. Director Of Nursing/Assistant Director Of Nursing/Unit Manager/Designee to complete random observations of residents while dining to ensure dignity is maintained. Observations will contain 10 residents/week x 3 months, then as needed until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Committee Meeting. Modifications implemented as indicated.
Failure to Submit Timely MDS Assessments
Penalty
Summary
The facility failed to ensure accurate and timely completion of resident assessments for two residents. Resident #27 was admitted to the facility and later died there. An MDS assessment for death in the facility was completed but not submitted. Resident #82 was admitted and later discharged to the hospital. The last MDS assessment submitted for this resident was an admission assessment, and the discharge assessment was not submitted until a later date. Staff E, a Resident Care Specialist I RN, confirmed that Resident #27's MDS assessment should have been submitted and acknowledged that the discharge MDS assessment for Resident #82 was delayed. The staff member attributed these issues to a switch in electronic medical records systems, which caused them to work in two systems simultaneously.
Plan Of Correction
1. Residents #27 & #82's assessments were transmitted on. 2. Minimum Data Set (MDS) Coordinator/Designee has completed a review of facility resident Minimum Data Set assessments completed over the last 30 days to verify completed & transmitted timely. Follow up based on findings. 3. Staff Development Coordinator/Designee has completed education with current facility Minimum Data Set employees related to timely Minimum Data Set completion/submission. 4. Minimum Data Set Coordinator/Designee to complete monitoring to verify assessments completed/transmitted timely weekly x 3 months or until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Committee Meeting. Modifications implemented as indicated.
Failure to Facilitate Resident Participation in Activities
Penalty
Summary
The facility failed to provide activities according to the preferences of a resident, identified as Resident #71, who expressed a willingness to participate in activities if invited. During an observation and interview, the resident mentioned that they were not informed about activities and would likely attend if asked. The resident was observed in their room with a television on and was unaware of the activity calendar placed on a bulletin board in their room. Staff interviews revealed that the resident did not attend activities but went to therapy, and the activity department was supposed to visit the resident's room. The resident's care plan indicated a need for invitations, assistance, and encouragement to attend programs of interest, such as music programs, card games, and social visits. The care plan also included interventions like offering seating close to program leaders and providing 1:1 leisure visits. Despite these interventions, the resident's activity task documentation showed minimal participation in activities over the past 30 days, with only a few instances of engagement in entertainment and friendly visits. The Activity Director acknowledged the lack of documentation for the resident's participation in a recent music program and mentioned that the resident was on isolation for a period, which may have affected their ability to attend activities. The facility's policy on individual activities stated that such activities should be provided for residents who do not wish to attend group activities, making use of each resident's physical and mental abilities. However, the facility did not adequately document or facilitate the resident's participation in activities, as evidenced by the lack of recorded engagement and the resident's own statements about not being informed or invited to activities. The Director of Nursing mentioned that the facility conducts welcoming meetings and shows new residents the activity calendar, but the follow-up on these procedures appeared insufficient in this case.
Plan Of Correction
1. Resident #71 has been discharged from the facility. 2. Activities Director/Designee has completed a review of current facility residents to confirm that activities are provided per preference. Follow up based on findings. 3. Staff Development Coordinator/Designee has provided education to the Activity staff related to assisting and providing residents preferred activities. 4. Activities Director/Designee to monitor residents to verify that activities are provided per preference using a random sample of 10 residents weekly x 3 months, then quarterly as needed or until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Committee Meeting. Modifications implemented as indicated.
Failure to Coordinate Dialysis Communication
Penalty
Summary
The facility failed to coordinate communication with a dialysis center for a resident requiring dialysis services. The resident, who has end-stage renal disease and is dependent on renal dialysis, was observed not feeling well and expressed uncertainty about attending dialysis. Despite the facility providing transportation, there was a lack of completed communication forms from the dialysis center, which are essential for documenting medications given, vital signs, and any changes in condition. The forms for specific dates were incomplete, and there was no evidence in the progress notes that the facility attempted to contact the dialysis center for the missing information. Interviews with staff revealed that the communication forms were not consistently completed by the dialysis center, and there was no policy in place for dialysis communication. The Director of Nursing acknowledged difficulties in obtaining completed forms from the dialysis center and noted the absence of a facility policy for dialysis. The contract between the facility and the dialysis center requires the interchange of information and collaboration of care, which was not adequately fulfilled, as evidenced by the incomplete communication forms and lack of documented communication efforts.
Plan Of Correction
1. Resident #36 has been discharged from the facility. 2. Director Of Nursing/Designee has conducted a review of current facility residents to verify communication is completed as required. Follow up based on findings. 3. Staff Development Coordinator/Designee has completed education for licensed nurses related to communication requirements. 4. Director Of Nursing/Staff Development Coordinator/Unit Manager/Designee to complete monitoring of residents to verify communication documentation is present weekly x 3 months, then as needed until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Committee Meeting. Modifications implemented as indicated.
Medication Storage and Security Deficiency
Penalty
Summary
The facility failed to ensure medications were stored securely and were inaccessible to unauthorized personnel, visitors, and residents. During an observation of medication administration on the 800-hall, a thermal cooler was found on top of a medication cart with a bottle of over-the-counter medication labeled Lacto Probiotic. The staff member indicated that the Lacto Probiotic was left unattended on the cart because it needed to be refrigerated during the medication pass. This indicates a failure to adhere to the facility's policy that requires medications to be stored safely and securely. Additionally, on the 200-hall, a medication cart was left unlocked and unattended while a staff member administered insulin to a resident. The cart was moved from the resident's doorway to the nursing station for verification of the insulin amount, and then back to the area outside the resident's room. During the administration of the insulin, the cart was not visible to the staff, leaving it unsecured. The facility's policy mandates that medication carts be locked when not in direct view of the nurse administering medication, which was not followed in this instance.
Plan Of Correction
1. Identified medications were relocated to an appropriate storage area. 2. Director of Nursing/Designee have completed a review of medication carts to ensure medications were stored in a safe manner and inaccessible to unauthorized personnel. Follow up based on findings. 3. Staff Development Coordinator/Designee has completed education with licensed nurses related to medication storage standards. 4. Director of Nursing/Staff Development Coordinator/Unit Manager/Designee to observe medication carts to verify medications are stored in a safe manner and inaccessible to unauthorized personnel daily x 2 weeks, 3 x/ week x 2 weeks, weekly x 4, then monthly as needed or until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Committee Meeting. Modifications implemented as indicated.
Failure to Implement Timely Enhanced Barrier Precautions
Penalty
Summary
The facility failed to initiate timely Enhanced Barrier Precautions (EBP) for a resident admitted with surgical wounds. The resident, who was in the facility for rehabilitation following hip repair surgery, had two dressings on the left lower extremity but did not have any signage indicating EBP. This oversight was identified during an observation and interview with the resident, who confirmed the absence of EBP measures. Interviews with the Assisted Director of Nursing/Infection Control Preventionist (ADON/ICP) and the Director of Nursing (DON) revealed that the facility's policy required EBP for residents with wounds, including surgical wounds. The ADON/ICP acknowledged that the resident should have been placed on EBP upon admission. The DON admitted awareness of the issue and attributed it to the high turnover of admissions and discharges, indicating a need for improvement in implementing EBP for residents with wounds.
Plan Of Correction
1. Resident #345's plan of care was updated to include enhanced barrier precautions. 2. Director of Nursing/Designee have completed a review of current facility residents to confirm enhanced barrier precautions are implemented if indicated. Follow up based on findings. 3. Staff Development Coordinator/Designee has conducted education with licensed nurses related to implementation of enhanced barrier precautions. 4. Director of Nursing/Staff Development Coordinator/Unit Manager/Designee to complete monitoring of facility residents to verify enhanced barrier precautions are implemented if indicated daily x 4 weeks, weekly x 4 weeks, then monthly as needed or until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Meeting. Modifications implemented as indicated.
Dignity Concern in Resident Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident, identified as Resident #7, who was observed eating lunch in a high-traffic hallway while seated in a wheelchair. Two staff members were seen adjusting the resident in his chair, with one assisting him with his meal while standing over him. The resident's admission record indicated a need for assistance with personal care, and interviews with staff revealed that the resident was placed in the hallway for monitoring during meals. The Director of Nursing acknowledged that seating the resident in the hallway could be a dignity concern, and it was noted that the facility lacked a policy related to dignified dining.
Plan Of Correction
1. Resident #7's plan of care has been updated to reflect the dining preferences of the resident/resident representative. The residents representative has received information specific to dignified dining, who verbalized understanding. 2. Director of Nursing/Designee has completed observation of current facility residents while dining to verify dignity is maintained. Follow up based on findings. 3. Staff Development Coordinator/Designee has completed education for current facility employees related to maintaining resident dignity while dining. 4. Director of Nursing/Assistant Director of Nursing/Unit Manager/Designee to complete random observations of residents while dining to ensure dignity is maintained. Observations will contain 10 residents/week x 3 months, then as needed until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Committee Meeting. Modifications implemented as indicated.
Delayed Egress Door Malfunction
Penalty
Summary
The facility was found to have a deficiency related to the maintenance of delayed egress exit doors, as observed during a survey conducted on February 11, 2025. During a tour of the facility with the maintenance director, it was noted that the delayed egress exit door from the main dining room failed to close and latch properly when tested. This issue was identified as a failure to comply with the requirements set forth in NFPA 101, which governs the safety and functionality of egress doors in healthcare facilities. The maintenance director, who was present during the observation, acknowledged that the door should have closed and latched automatically but required assistance to do so. This indicates a lapse in the facility's adherence to safety protocols, as the door's inability to function correctly could impede safe egress in an emergency situation. The deficiency was documented based on both observation and interview, highlighting the importance of maintaining functional egress systems to ensure the safety of residents and staff. The findings were discussed with both the maintenance director and the facility administrator during the exit conference on the same day. The report does not mention any specific residents being directly affected by this deficiency, nor does it provide details on any immediate consequences resulting from the door's malfunction. However, the failure to maintain the door in accordance with NFPA 101 standards represents a significant oversight in the facility's safety measures.
Plan Of Correction
Preparation and/or execution of this Plan of Correction does not constitute admission or agreement by the provider of the truth of the items alleged or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by the provision of Federal and State Laws code section 1280 and 42 CFR 483.1. 1. Identified doors repaired, currently closing/latching as intended. 2. Maintenance Director/Designee completed observation of other facility exit doors to verify delayed egress maintained. 3. Administrator provided education for current facility Maintenance Department regarding egress doors. 4. Maintenance Director/Designee to complete monthly preventative maintenance testing of exit doors to verify delayed egress maintained. Findings to be reviewed at the monthly QAPI Committee Meeting. Modifications as indicated based on findings. Preparation and/or execution of this Plan of Correction does not constitute admission or agreement by the provider of the truth of the items alleged or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by the provision of Federal and State Laws code section 1280 and 42 CFR 483.1. 1. Identified doors repaired, currently closing/latching as intended. 2. Maintenance Director/Designee completed observation of other facility exit doors to verify delayed egress maintained. 3. Administrator provided education for current facility Maintenance Department regarding egress doors. 4. Maintenance Director/Designee to complete monthly preventative maintenance testing of exit doors to verify delayed egress maintained. Findings to be reviewed at the monthly QAPI Committee Meeting. Modifications as indicated based on findings.
Failure to Maintain Smoke Barrier Integrity
Penalty
Summary
The facility failed to maintain the continuity of smoke barriers in accordance with NFPA 101 standards. During a facility tour conducted on February 11, 2025, between 1:00 p.m. and 4:00 p.m., it was observed that there was an unsealed penetration in the smoke barrier above the smoke door by room 106. Additionally, there was an untested blowout patching in the smoke barrier above the ceiling in the same area. These deficiencies were identified through both observation and interview with the maintenance director. The maintenance director acknowledged the presence of the unsealed penetration and the untested blowout patching during the tour. He stated that he had already removed several blowout patches but admitted that this particular one had not been addressed, and the barrier was not sealed to the deck. These findings were reviewed with both the maintenance director and the administrator during the exit conference on the same day.
Plan Of Correction
1. Identified unsealed penetration & smoke barrier has been sealed. Identified untested blowout patching in the smoke barrier above the ceiling has been removed/repaired. 2. Maintenance Director/Designee completed observation of other facility smoke barriers to verify they are maintained in accordance with NFPA 101. 3. The administrator provided education for current facility Maintenance Department regarding smoke barrier maintenance. 4. Maintenance Director/Designee to complete monthly observation of smoke barriers to verify they are maintained in accordance with NFPA 101. Findings to be reviewed at the monthly QAPI Committee Meeting. Modifications as indicated based on findings.
Outdated Certification of Oxygen Concentrator
Penalty
Summary
The facility failed to maintain patient care related electrical equipment (PCREE) in accordance with NFPA 99 standards. During a facility tour, it was observed that an oxygen concentrator in the rehabilitation area had an outdated PCREE certification, with the last certification dated July 2021. This indicates that the equipment had not been tested or certified for compliance for a significant period, contrary to the requirements that all PCREE be tested before being put into service and after any repair or modification. The maintenance director, who was present during the tour, acknowledged that the concentrator was provided by a rental company. This suggests a lapse in the facility's oversight of equipment maintenance and certification, particularly for equipment sourced externally. The findings were discussed with the maintenance director and the administrator during the exit conference, highlighting the facility's failure to adhere to established protocols for electrical equipment testing and maintenance.
Plan Of Correction
1. Identified concentrator was removed from service, PCREE certification service completed. 2. Maintenance Director/Designee completed observation of other facility concentrators to verify PCREE certification is completed as required. 3. The administrator provided education for current facility Maintenance Department regarding PCREE maintenance requirements. 4. Maintenance Director/Designee to complete monthly observation of facility concentrators to ensure PCREE certification is completed as required. Findings to be reviewed at the monthly QAPI Committee Meeting. Modifications as indicated based on findings.
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.
