Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Annes Nursing Center, St Annes Residence Inc during CMS and state inspections, most recent first.
Failure to Use Ordered Mechanical Lift During Transfer: A resident with ESRD, dialysis dependence, cognitive impairment, and an order for mechanical-lift transfers was moved from bed to wheelchair by a CNA without the lift. After the transfer, the resident reported RLE pain, and x-rays showed a proximal tibia fracture with additional fibular and tibial shaft fractures. Staff later confirmed the resident should have been transferred with a two-person mechanical lift.
A resident with severe cognitive impairment, palliative care status, and contracted upper extremities developed left arm edema that progressed to swelling, discoloration, and loss of the usual contracted position. Staff monitored the arm, gave Tylenol, and notified hospice, but the resident was not transferred promptly; later assessment led to hospital transfer, where X-ray showed an acute displaced humerus fracture.
Two residents with complex medical histories experienced falls and changes in condition, but their care plans remained generic and unchanged, lacking individualized interventions despite facility policy requiring tailored, measurable plans. Staff interviews confirmed that specific interventions were not implemented after falls, and care plans did not address unique needs such as communication barriers or evolving clinical status.
Two residents experienced lapses in supervision and improper use of fall prevention devices during personal care, resulting in one resident falling from bed and sustaining a head injury while on anticoagulant therapy, and another being left at risk of falling due to staff not properly using bed wedges. Staffing shortages and lack of timely intervention updates contributed to these deficiencies.
The facility failed to follow physician orders for two residents requiring floor mats and one resident needing oxygen at a specific rate. A resident was observed with only one floor mat instead of two, and another had a mat improperly placed, both contrary to orders. Additionally, a resident receiving hospice care was given oxygen at 1.25 liters per minute instead of the prescribed 2.0 liters per minute. These deficiencies highlight lapses in adhering to prescribed safety and care protocols.
A resident was incorrectly coded in the MDS as being discharged to a hospital instead of an Assisted Living Facility. The error was identified through a review of clinical records and discharge assessments, which showed a discrepancy between the MDS coding and the nurse's notes. The MDS Coordinator acknowledged the mistake, citing a lapse in the verification process between the Social Services and MDS departments.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in care. One resident had inadequate floor mat interventions, resulting in falls. Another resident also lacked proper floor mat placement, increasing fall risk. A third resident received oxygen at a lower rate than prescribed, causing low oxygen saturation. Staff communication and adherence to care plans were insufficient.
A resident's drainage bag was improperly placed above the side rail, increasing the risk of dislodgement. An RN Supervisor confirmed the bag should be lower than the resident to ensure proper flow. The resident had a diagnosis of hyperplasia with lower tract symptoms and was at increased risk due to retention. The facility's policy required the drainage bag to be positioned lower to allow gravity drainage, but this was not followed.
A resident was discharged to an Assisted Living Facility, but the MDS was incorrectly coded to indicate a discharge to a Short-Term General Hospital. The error was acknowledged by the MDS Coordinator, who explained that the Social Services department inputs discharge information, while the MDS department verifies it. The facility's policy requires accurate and ongoing assessments, which was not adhered to in this case.
A facility failed to accurately complete a Level I PASRR for a resident, as the documentation did not include any diagnosis despite the resident's history of mental illness. The PASRR screen decision-making section was left unchecked, which was inconsistent with the resident's medication records and evaluation notes. Interviews with staff revealed discrepancies in the PASRR documentation, and the failure to initiate a new resident review earlier was a critical oversight.
Surveyors found that the facility did not consistently develop or implement care plans for two residents requiring bilateral floor mats for fall prevention, as only one mat was in place and care plans lacked the required intervention. Additionally, a resident receiving oxygen therapy was observed with a flow rate below the physician's order, and staff failed to verify the correct rate during rounds, resulting in low oxygen saturation until corrected.
A resident with an indwelling urinary catheter was found with the drainage bag positioned above the bladder level, contrary to facility policy and standard infection prevention practices. Nursing staff and the DON confirmed that the drainage bag should be kept below the bladder to prevent backflow and infection, but this protocol was not followed for a resident with BPH, obstructive uropathy, and a pressure ulcer.
A resident with severe cognitive impairment and end-stage cardiac disease was observed receiving oxygen at 1.25 L/min instead of the prescribed 2 L/min via nasal cannula. Staff failed to verify and adjust the oxygen flow rate as ordered, resulting in a critically low oxygen saturation. Facility policy required staff to ensure the prescribed oxygen rate, but this was not followed.
A QAA committee failed to correct a recurring infection control deficiency when a resident's respiratory equipment, including a nebulizer and tubing, was found stored uncovered on a bedside table next to a live plant. Despite regular interdisciplinary meetings and established policies, the same issue was observed again, showing ineffective resolution of the previously cited problem.
Staff did not follow infection control protocols for storing respiratory devices and cleaning shared blood pressure cuffs between residents. An incentive spirometer was left uncovered on a resident's nightstand, and a nurse used the same blood pressure cuff on multiple residents without disinfecting it, contrary to facility policy and expectations.
The facility failed to maintain its automatic sprinkler system according to NFPA 101 standards. During a survey, it was found that several sprinklers were covered by foreign material, corroded, or damaged, particularly in the kitchen and main entrance. Additionally, there was a lack of a spare dry sprinkler for the freezer in the mechanical room. These issues were acknowledged by the Maintenance Director and discussed with the Administrator.
The facility failed to document one of the required quarterly fire drills for the third quarter on the second shift in 2024, as per NFPA 101 standards. This deficiency was identified during a records review with the Maintenance Director, who acknowledged the missing documentation. The issue was also discussed with the Administrator during the exit conference.
During a Life Safety Survey, an unsecured oxygen cylinder was found in the Dialysis Room of the facility. The cylinder was in use by a resident, and the deficiency was acknowledged by both the Maintenance Director and the Administrator. This incident highlights a failure to comply with NFPA 101 standards for gas equipment storage.
Failure to Use Ordered Mechanical Lift During Transfer
Penalty
Summary
The facility failed to ensure that a resident who had an order to be transferred with a mechanical lift was actually transferred using that lift. Resident #1 had diagnoses including end stage renal disease and dependence on renal dialysis, and the physician’s orders included fall precautions, safety precautions, and transfer with use of a mechanical lift. The resident’s care plan also identified decreased mobility and unsteady gait, and the MDS documented cognitive impairment and dependence or substantial assistance with multiple activities of daily living. On 10/09/2025, Staff G, a CNA, transferred the resident from the bed to the wheelchair without using the ordered mechanical lift. Staff G later stated she used proper body mechanics, twisted the resident into the chair, and was only trained to transfer the resident without the lift, although she also acknowledged she knew the resident required a mechanical lift and that the lift transfer was a two-person procedure. After the transfer, the resident complained of pain in the right lower extremity, and staff noted the change in condition and obtained x-rays. The x-ray results showed a proximal right tibia fracture with diffuse osteopenia, and the resident was transferred to the hospital for further evaluation. The hospital record documented acute comminuted fractures of the right fibular shaft and an acute oblique fracture of the right proximal tibia shaft. Interviews with staff confirmed that the resident had been transferred without the ordered lift and that the resident reported pain after the transfer.
Delayed Transfer for Worsening Arm Injury
Penalty
Summary
The facility failed to ensure timely higher-level care and treatment for a resident with bilateral contracted upper extremities when the resident developed swelling in the left arm that worsened over time and later showed discoloration and loss of the usual contracted position. The resident had diagnoses including Degenerative Disease of the Nervous System and palliative care status, was severely cognitively impaired, nonverbal, and dependent on staff for all activities of daily living. The resident was observed in bed with a sling on the left arm during the survey, and the clinical record showed the resident had been receiving hospice services. Nursing documentation showed mild edema to the left arm was first noted and hospice was notified, with instructions to continue monitoring. Subsequent notes and staff statements described the arm as swollen, elevated on a pillow, and treated with Tylenol for possible pain, but no immediate transfer occurred. Staff accounts differed on the appearance of the arm during the day, with some reporting only slight edema and no bruising, while later staff observed swelling throughout the arm, bruising or discoloration to the inner arm, and that the arm was no longer contracted as usual. When the night shift nurse assessed the resident, the nurse documented swelling throughout the arm with discoloration and noted the change in the resident’s contracted arm position. Hospice was contacted, a hospice LPN evaluated the resident, and the family was called for permission to transfer the resident to the hospital. Hospital imaging revealed an acute mid humerus spiral fracture with displacement. Interviews with facility leadership showed the facility recognized it was responsible for residents receiving hospice services and that sudden or worsening changes in condition could require emergency services, yet the resident’s worsening arm condition was not transferred for more than a day after the initial swelling was noted.
Failure to Individualize Resident Care Plans Following Falls
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for two residents, as evidenced by care plans that contained generic interventions not tailored to each resident's specific health needs and functional status. For one resident with dementia and impaired mobility, the care plan remained largely unchanged over multiple quarterly reviews, despite several documented falls, including incidents resulting in a skin tear and a hematoma that required hospitalization. The interventions listed were broad and not specific to the resident's evolving condition, and there was no evidence of new or revised interventions following significant events such as falls. Another resident with Alzheimer's disease, COPD, and diabetes also had a care plan that did not reflect individualized interventions, even after experiencing a fall. The care plan problems and interventions remained static over an extended period, with only minor updates that did not address the resident's changing clinical status or specific needs. Observations indicated the resident was confused and communicated in both English and Spanish, but the care plan did not address these unique communication needs or other individualized factors. Interviews with facility staff, including the Care Plan Coordinator and the resident's physician, revealed a lack of awareness and implementation of specific interventions following falls. The Care Plan Coordinator was unable to identify what interventions were implemented after documented falls, and the physician confirmed that expected fall precautions were not put in place after the initial incident. The facility's policy requires individualized, measurable care plans based on assessment findings, but this was not followed for the residents in question.
Failure to Provide Adequate Supervision and Fall Prevention Measures
Penalty
Summary
The facility failed to provide adequate supervision and implement safety measures for two residents, resulting in accident hazards and increased risk of injury. One resident with severe cognitive impairment and a history of falls experienced a fall from bed during personal care. The CNA providing care left the resident unattended on the bed while changing gloves, during which time the resident rolled off the bed and sustained a head injury with a large hematoma and bleeding. The resident was on anticoagulant therapy, which was not communicated to emergency services by facility staff. Prior to this incident, the resident had a previous fall with injury, but no additional fall prevention interventions were implemented until after the second fall. The care plan was not updated with appropriate interventions such as floor mats and bed wedges until after the injury occurred. Staff interviews revealed that the CNA assigned to the resident had limited experience, having only worked in the facility for a few months and often worked alone despite being assigned a high number of residents. The CNA reported difficulty working in pairs due to staffing levels, and on the night of the incident, each CNA was responsible for 14 residents. The DON and Risk Manager acknowledged that there was a gap in communication regarding the implementation of fall prevention interventions after the first fall, and that a physician's order was required for certain safety devices, which contributed to the delay in implementing these measures. In a separate incident, another resident was left at risk of falling during personal care when staff failed to properly use fall prevention devices. During morning care, one CNA left the room while the other continued care, leaving the resident near the edge of the bed with the side padding/wedge down. The CNA admitted to forgetting to raise the side wedge and not positioning the resident in the middle of the bed as required. The unit manager confirmed that staff should not have left the side wedge down and should have called for help if needed. Both incidents demonstrate a failure to maintain an environment free from accident hazards and to provide adequate supervision and use of assistive devices as required by facility policy.
Failure to Follow Physician Orders for Safety Equipment and Oxygen Administration
Penalty
Summary
The facility failed to adhere to physician orders for two residents who required floor mats for safety. Resident #25 was observed in bed with only one floor mat on the left side, despite having a physician's order for two floor mats to be placed on each side of the bed. The RN Supervisor confirmed the need for two mats but was unable to locate the second mat in the room. A CNA assigned to Resident #25 acknowledged that the resident usually only had one mat in place, which contradicts the physician's order. This oversight is significant given Resident #25's history of being found on the floor, indicating a potential risk of falls. Similarly, Resident #52 was observed with one floor mat in place on the right side of the bed, while the other mat was folded and leaning against the nightstand. This setup did not comply with the physician's order for floor mats to be used when the resident is in bed. The CNA present during the observation did not provide an explanation for the improper placement of the floor mats, which could compromise the resident's safety, especially considering their severe dependency for Activities of Daily Living (ADL). Additionally, the facility did not follow the physician's order for Resident #95, who was receiving hospice care and required humidified oxygen at a continuous rate of 2.0 liters per minute. Instead, the oxygen was observed to be administered at 1.25 liters per minute. The Director of Nursing confirmed that the oxygen should be delivered at the prescribed rate, whether continuous or as needed. This discrepancy in oxygen administration could have implications for the resident's health, given their severe dependency on ADLs and altered mental status.
Plan Of Correction
Immediate Action: Resident sample # 25- care plan was reviewed and revised to include implementation of floor mats per physician orders by the MDS Nurse. Resident sample # 52 floor mat was placed as per physician orders. The Nurse and CNA were educated by the Nurse Manager on expectation of following physician orders and/or implementing the identified appropriate care plan interventions for floor mats. Resident sample #95 The was increased from 1.25 liters per minute to 2 Liters per minute as per physician orders. saturation was checked and was reported to the Hospice team. The Nurse was educated by the Nurse Manager on expectation of following physician orders and/or implementing the identified appropriate care plan interventions for use. Identification of Residents with potential to be affected: All residents in the facility have the potential to be affected. Interdisciplinary review and verification of care plan interventions and orders for floor mats and use. System Changes: The facility Prevention Policy and Medication Administration Policy were reviewed for accuracy. Nurses and CNAs were educated and trained on the Falling Star Program and use of floor mats and resident use as indicated in the physician orders by the Director of Nursing and Risk Manager. Licensed nursing staff are to verify and document in the Treatment Administration Record the use of floor mats and orders for use every shift. Licensed nursing staff were educated by the Director of Nursing and the Assistant Director of Nursing on medication administration with emphasis on right dosage for use. Monitoring: Surveillance Rounds by Nurse Manager/designee to audit for compliance the residents with orders for floor mats and residents with use 3x a week for 90 days. The results of the rounds will be reported to the monthly Quality Assurance Performance Improvement Committee. Responsible Party: Unit Managers, Supervisor, Risk Manager, ADON and DON.
MDS Coding Error for Resident Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, resulting in a discrepancy in the discharge information. The resident, who was initially admitted from a Short-Term General Hospital with a medical diagnosis of other specified injuries, was scheduled to be discharged to an Assisted Living Facility (ALF). However, the MDS was incorrectly coded to indicate that the resident was discharged to a Short-Term General Hospital instead of the ALF. The error was identified during a review of the resident's clinical records and discharge assessment. The discharge assessment MDS reference indicated a planned discharge, but the section for discharge status incorrectly coded the resident as being discharged to a hospital. This was contrary to the nurse's notes, which documented that the resident was discharged to the ALF and transported via wheelchair. During an interview, the MDS Coordinator acknowledged the error, explaining that the Social Services department is responsible for inputting discharge information, while the MDS department verifies the timely submission of this information. The coordinator accepted responsibility for the error on behalf of the department. The facility's policy requires a complete admission observation/assessment to develop a care plan tailored to the resident's needs, with ongoing assessments throughout the resident's stay.
Plan Of Correction
Immediate Action: The Minimal Data Set dated for sample resident #200 was modified for discharge status to an Assisted Living Facility in section A 2105 on was resubmitted on. Responsible staff member was re-educated on accurate Minimal Data Set completion by the MDS Nurse. Identification of Residents with potential to be affected: All residents that are discharged have the potential to be affected. The discharge assessment- return not and return MDSS completed since will be audited for discharge location accuracy and modified per Resident Assessment Instrument Manual. Inaccuracies identified will be corrected and resubmitted. System Changes: All resident discharges will be discussed by the Interdisciplinary Team on the next business day to determine discharge disposition. Discharges will be completed by the MDS Nurses in the entirety as of. Monitoring: Monthly audits of all Discharge Assessments will be audited weekly for accuracy for the next 3 months. An audit sheet will be maintained to demonstrate accurate completion of section A2105. Results will be reported monthly to the Quality Assurance Performance Improvement committee. At the end of 3 months, the Quality Assurance Performance Improvement Committee will reassess the need for ongoing audit frequency and duration. Responsible Party: MDS Nurses/ Coordinators
Deficiencies in Care Planning and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in their care. Resident #25 was observed with only one floor mat in place, despite a physician's order for two mats to prevent falls. The care plan for this resident did not include interventions for floor mats, and staff were unaware of the correct protocol, resulting in the resident being found on the floor multiple times. Resident #52 was also affected by inadequate care planning, as they were observed with only one floor mat in place, contrary to the prescribed two mats. The staff failed to communicate effectively about the required interventions, and the resident was found on the floor on several occasions. The care plan for this resident did not adequately address the need for floor mats, contributing to the risk of falls. Resident #95 experienced a deficiency in care related to the administration of oxygen. The resident was observed receiving oxygen at a rate lower than the physician's order, which led to a dangerously low oxygen saturation level. The staff did not verify the oxygen delivery rate during rounds, resulting in a delay in adjusting the oxygen to the prescribed level. This oversight in care planning and execution posed a significant risk to the resident's health.
Plan Of Correction
Immediate Action: Resident sample #25 - care plan was reviewed and revised to include implementation of floor mats per physician orders by the MDS Nurse. Resident sample #52 - floor mat was placed as per physician orders and care plan. The Nurse and CNA were educated by the Nurse Manager on the expectation of following physician orders and/or implementing the identified appropriate care plan interventions for floor mats. Resident sample #95 - the flow rate was increased from 1.25 liters per minute to 2 liters per minute as per physician orders and care plan. Saturation was checked and reported to the Hospice team. The Nurse was educated by the Nurse Manager on the expectation of following physician orders and/or implementing the identified appropriate care plan interventions for use. Identification of Residents with potential to be affected: All residents in the facility have the potential to be affected. Interdisciplinary review and verification of care plan interventions and orders for floor mats and use. System Changes: The facility Prevention Policy and Medication Administration Policy were reviewed for accuracy. Nurses and CNAs were educated and trained on the Falling Star Program and use of floor mats and resident use as indicated in the physician orders and care plan by the Director of Nursing and Risk Manager. Licensed nursing staff are to verify and document in the Treatment Administration Record the use of floor mats and orders for use every shift. Licensed nursing staff were educated by the Director of Nursing and the Assistant Director of Nursing on medication.
Improper Placement of Drainage Bag in Resident's Care
Penalty
Summary
The facility failed to provide adequate and appropriate healthcare and treatment services for a resident, as evidenced by the improper placement of a drainage bag. During an observation, the drainage bag was found anchored to the side rail above the resident, increasing the risk of dislodgement. A Registered Nurse (RN) Supervisor confirmed that the drainage bag should be positioned lower than the resident to facilitate proper flow and prevent complications. The RN Supervisor adjusted the drainage bag to the correct position after being informed of the issue. The resident involved had a diagnosis that included hyperplasia with lower tract symptoms and was at increased risk due to retention. The care plan for the resident included maintaining the anchoring device to prevent dislodgement and monitoring the site for skin integrity. The facility's policy stated that the drainage bag should be kept as a closed system and positioned lower than the resident to allow drainage by gravity. Despite these guidelines, the improper placement of the drainage bag was observed, indicating a failure to adhere to established protocols.
Plan Of Correction
Immediate Action: Drainage bag for affected sample resident #184 was immediately repositioned below level of the to prevent. Care plan reviewed for accuracy. Identification of Residents with potential to be affected: All residents with using a drainage system, have potential to be affected. System Changes: Control Policy was reviewed for accuracy. All licensed Nursing staff were educated and trained by the Control Preventionist, Director of Nursing, and the Assistant Director of Nursing in care with emphasis on proper placement of Drainage appliance/bag. They were required to demonstrate return demonstration on proper placement on drainage appliance/bag. Monitoring:
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, resulting in a discrepancy between the recorded discharge location and the actual discharge destination. The resident, who was admitted from a Short-Term General Hospital with a medical diagnosis of other specified injuries, was scheduled to be discharged to an Assisted Living Facility (ALF). However, the MDS was incorrectly coded to indicate that the resident was discharged to a Short-Term General Hospital instead of the ALF. The error was identified during a review of the resident's clinical records and was confirmed by a nurse's note documenting the resident's discharge to the ALF. During an interview, the MDS Coordinator acknowledged the mistake, explaining that the Social Services department is responsible for inputting discharge information, while the MDS department verifies the information's timely submission. The coordinator accepted responsibility for the error on behalf of the department. The facility's policy requires ongoing and individualized assessments to meet residents' needs, but this process was not accurately followed in this instance.
Plan Of Correction
Immediate Action: The MDS Set dated for sample resident #200 was modified for discharge status to an Assisted Living Facility in section A 2105 on was resubmitted on. Responsible staff member was re-educated on accurate MDS completion by MDS Nurse. Identification of Residents with potential to be affected: All residents that are discharged have the potential to be affected. The discharge assessment- return not and return MDSS completed since, will be audited for discharge location accuracy and modified per Resident Assessment Instrument Manuel. Inaccuracies identified will be corrected and resubmitted. System Changes: All resident discharges will be discussed by the Interdisciplinary Team on the next business day to determine discharge disposition. Discharges will be completed by the MDS Nurses in the entirety as of. Monitoring: Monthly audits of all Discharge Assessments will be audited weekly for accuracy for the next 3 months. An audit sheet will be maintained to demonstrate accurate completion of section A2105. Results will be reported monthly to the Quality Assurance Performance Improvement Committee. At the end of 3 months, the Quality Assurance Performance Improvement Committee will reassess the need for ongoing audit frequency and duration. Responsible Party: MDS Nurses/ Coordinators
Failure to Accurately Complete PASRR for Resident
Penalty
Summary
The facility failed to accurately complete a Level I Preadmission Screening and Resident Review (PASRR) for a resident, identified as Resident #166, out of five residents investigated for Level I PASRR. The deficiency was identified during a survey when it was found that the PASRR documentation for Resident #166 did not include any diagnosis, despite the resident having a history of mental illness. The PASRR screen decision-making section did not have any diagnosis checked, which was a significant oversight given the resident's medical history. The record review revealed that Resident #166 had an admission date with unspecified diagnoses. The Minimum Data Set (MDS) indicated that the resident was not considered by the state level II PASRR process to have a serious mental illness or intellectual disability, which was inconsistent with the resident's medication records and evaluation notes. The resident was taking medications that suggested a history of mental illness, yet this was not reflected in the PASRR documentation. Interviews with facility staff, including the Social Services Director and the Director of Care Coordination, revealed that there were discrepancies in the PASRR documentation. The Social Services Director acknowledged the discrepancies and noted that a resident review was scheduled to occur within 30 days of the evaluation to assess any changes in the patient's condition. The Director of Care Coordination stated that significant changes in a resident's condition are typically evident through behavioral changes, and the facility reviews PASRRs within 30 days for further evaluation. However, the failure to initiate a new resident review for Resident #166 earlier to include all mental illness diagnoses was a critical oversight.
Plan Of Correction
Immediate Action: The Pre Admission Screening and Resident Review for sample resident #166 was reviewed, updated, and submitted to the appropriate state agency on . Confirmation of update and receipt of determination has been obtained and was filed in residents chart. The staff member responsible received a 1:1 education on procedure for completing the Pre Admission Screening and Resident Review by Corporate Director of Social Service. Identification of Residents with potential to be affected: All residents have the potential to be affected. System Changes: The PASRR Policy was reviewed with all Social Work Staff responsible for completing PASRR Level I and requirement. All newly admitted residents will have the Pre Admission Screening and Resident Review reviewed for accuracy and resubmitted when inaccuracies are identified. Monitoring: A Pre Admission Screening and Resident Review audit for all admissions and present residents are being reviewed by the Social Work Director to ensure accurate completion. The Audit results will be submitted to the monthly Quality Assurance Performance Improvement Team for review. The audit will continue for 90 days or until the committee agrees substantial compliance is achieved. Responsible Party: Director of Social Work Corporate Director of Social Work/ Care Coordinator
Failure to Implement and Document Required Fall and Respiratory Care Interventions
Penalty
Summary
The facility failed to develop and implement appropriate care plans for residents with specific needs, as evidenced by observations, interviews, and record reviews. For two residents with physician orders for bilateral floor mats to prevent falls, the care plans did not include interventions for floor mats, and the mats were not consistently in place as ordered. One resident was observed with only one floor mat in place when two were required, and staff interviews confirmed that the protocol was not consistently followed. Documentation showed a history of falls for these residents, and physician orders clearly specified the need for bilateral floor mats every shift, yet this intervention was omitted from the care plans and not reliably implemented in practice. Additionally, the facility failed to implement a respiratory care plan for a resident receiving oxygen therapy. The resident was observed receiving oxygen at a flow rate lower than the physician-ordered amount, and staff did not verify the oxygen flow rate during rounds. The resident's oxygen saturation was found to be critically low until the flow rate was corrected by staff. The care plan for this resident did include the need for oxygen therapy at the prescribed rate, but the intervention was not properly implemented, resulting in a deviation from the physician's order. These deficiencies were identified through direct observation, staff interviews, and review of medical records and care plans. The facility's own care planning policy requires individualized, interdisciplinary plans of care based on assessment findings and physician orders, but these requirements were not met for the residents in question, leading to lapses in the delivery of ordered interventions for fall prevention and respiratory care.
Improper Positioning of Urinary Catheter Drainage Bag
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was observed lying in bed with the catheter drainage bag anchored to the side rail above the resident's head, rather than below the level of the bladder. This placement was confirmed by a Registered Nurse (RN) Supervisor, who acknowledged that the drainage bag should be positioned lower than the bladder to facilitate proper urine flow. The RN Supervisor adjusted the drainage bag after the issue was pointed out. Interviews with nursing staff and the Director of Nursing confirmed that facility protocol and policy require the drainage bag to be kept below the bladder to prevent backflow and potential infection. The resident involved had a medical history including benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, obstructive uropathy, and a pressure ulcer. Physician orders and the care plan specified the need for indwelling catheter care every shift and interventions to prevent infection, including proper anchoring of the catheter. Facility policy also outlined the importance of maintaining the drainage bag below bladder level as part of infection prevention. The failure to position the drainage bag correctly constituted a lapse in following established protocols and care plans for catheter management.
Failure to Administer Oxygen at Prescribed Rate
Penalty
Summary
The facility failed to provide appropriate respiratory care consistent with professional standards of practice for a resident receiving oxygen therapy. Observations revealed that the resident, who had severe cognitive impairment and was dependent on ADLs, was receiving oxygen at 1.25 liters per minute via nasal cannula, despite a physician's order for 2 liters per minute. This discrepancy was observed on two separate occasions, and photographic evidence was obtained. The resident's care plan and physician's orders both specified the need for continuous oxygen at 2 liters per minute, but staff did not ensure the prescribed rate was being delivered. A registered nurse acknowledged not verifying the oxygen flow rate during morning rounds. The resident had a history of acute chronic diastolic congestive heart failure, nonrheumatic aortic valve stenosis, and was receiving hospice care. During the survey, the resident's oxygen saturation was found to be critically low at 76% while on the incorrect oxygen flow rate. The facility's policy required staff to set the oxygen concentrator to the prescribed flow rate, but this was not followed, resulting in the resident receiving less oxygen than ordered.
Repeated Infection Control Deficiency Due to Uncovered Respiratory Equipment
Penalty
Summary
The facility's Quality Assurance and Assessment (QAA) committee failed to implement an effective plan of action to correct a previously identified quality deficiency related to infection prevention and control. During a recertification survey, it was observed that respiratory equipment, specifically a nebulizer and tubing, was stored uncovered on a bedside table next to a live plant for one resident. This storage practice did not comply with infection control procedures and was previously cited as a deficiency under F 880-Infection Prevention & Control. The facility's records confirmed that the QAA committee met monthly and included a range of interdisciplinary team members, such as the Administrator, Medical Director, DON, ADON, Infection Control Preventionist, and others. Despite these regular meetings and the existence of policies aimed at monitoring and improving care quality, the same infection control issue was observed again, indicating that the committee did not effectively address or resolve the previously cited deficiency.
Failure to Implement Infection Control Practices for Respiratory Devices and Shared Equipment
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for three out of seven sampled residents. For one resident with a history of COPD, pulmonary embolism, and recent hospitalization for respiratory issues, an incentive spirometer was observed on the nightstand without a protective covering when not in use. The registered nurse confirmed that the device should be stored in a plastic bag and dated, but it was left uncovered to keep it readily available. The Director of Nursing also acknowledged that, although there was no formal protocol, the expectation was for the device to be bagged when not in use. Additionally, staff failed to disinfect the blood pressure cuff on the vital signs machine between use on different residents. One resident had their blood pressure measured with a cuff that was not cleaned before or after use, and the same cuff was subsequently used on another resident without disinfection. The registered nurse did not use disinfectant wipes, which were not present on the machine, and admitted to not cleaning the cuff due to nervousness. The Director of Nursing stated that staff are expected to clean the vitals machine with bleach wipes between residents, as outlined in the facility's infection control policy.
Deficiency in Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 101 standards, as observed during a Life Safety Survey tour. During the inspection, it was noted that several sprinklers in different areas of the facility were either covered by foreign material, corroded, or damaged. Specifically, in the kitchen, 8 out of 28 sprinklers were found to be in such a condition. Additionally, at the main entrance on the first floor, 2 out of 3 sprinklers were similarly affected. Further deficiencies were observed in the first-floor mechanical room across from the chapel, where there was a lack of a spare dry sprinkler for the freezer, and no means to restore service was available. These issues were acknowledged by the Maintenance Director during the survey and were also discussed with the Administrator during the exit conference. The report highlights that the facility did not adhere to the required standards for the inspection, testing, and maintenance of its water-based fire protection systems as outlined in NFPA 25. The lack of proper maintenance and availability of necessary equipment could potentially compromise the safety and effectiveness of the sprinkler system in the event of a fire.
Plan Of Correction
5/16/25 Immediate Action: A Certified Fire Protection contractor completed an inspection of the building on 4/8/2025. The proposal was signed April 30, 2025 to replace corroded and damaged sprinklers. The contract company is pending material availability which includes spare dry sprinkler for freezer. Identification of Residents with potential to be affected: All in-house residents have the potential to be affected. System Changes: The facility reviewed the preventive maintenance program to include a visual inspection of sprinkler heads is conducted monthly. Maintenance staff were retrained / educated on identifying signs of corrosion and damage to the sprinkler heads during the visual inspections. Monitoring: Director of Maintenance / designee will maintain a log of inspections and report will be present in the monthly Quality Assurance Performance Improvement committee meeting. Responsible Party: Director of Maintenance 5/16/25 Immediate Action: A Certified Fire Protection contractor completed an inspection of the building on 4/8/2025. The proposal was signed April 30, 2025 to replace corroded and damaged sprinklers. The contract company is pending material availability which includes spare dry sprinkler for freezer. Identification of Residents with potential to be affected: All in-house residents have the potential to be affected. System Changes: The facility reviewed the preventive maintenance program to include a visual inspection of sprinkler heads is conducted monthly. Maintenance staff were retrained / educated on identifying signs of corrosion and damage to the sprinkler heads during the visual inspections. Monitoring: Director of Maintenance / designee will maintain a log of inspections and report will be present in the monthly Quality Assurance Performance Improvement committee meeting. Responsible Party: Director of Maintenance
Failure to Document Quarterly Fire Drill
Penalty
Summary
The facility failed to perform fire drills in accordance with NFPA 101 standards, as evidenced by a lack of documentation for one of the four required fire drills in 2024. Specifically, the missing documentation pertained to the fire drill that was supposed to be conducted during the third quarter on the second shift. This deficiency was identified during a records review process conducted between noon on April 7, 2025, and 5:00 pm on April 8, 2025, with the Maintenance Director present. During the staff interview conducted within the same timeframe, the Maintenance Director acknowledged the absence of documentation for the fire drill. This finding was also discussed and acknowledged by the Administrator during the exit conference. The report highlights that the facility did not meet the requirement of conducting fire drills at least quarterly on each shift, as mandated by NFPA 101.
Plan Of Correction
5/16/25 Immediate Action: A fire drill was conducted on the missed shift on May 9, 2025 to ensure that staff on the second shift are trained and prepared for emergency situations. Identification of Residents with potential to be affected: All in-house residents have the potential to be affected. System Changes: A fire drill schedule/calendar was created for the entire year which clearly indicates the required monthly drill shift. Monitoring: The Director of Maintenance will ensure the facility documentation is accurate regarding the scheduled shift. The schedule/calendar will be submitted to the monthly Quality Assurance Performance Improvement committee meeting. Responsible Party: The Director of Maintenance
Unsecured Oxygen Cylinder in Dialysis Room
Penalty
Summary
The facility failed to maintain gas equipment-cylinder and container storage in accordance with NFPA 101 standards. During a Life Safety Survey tour conducted between 11:00 am and 4:30 pm on April 8, 2025, an unsecured oxygen cylinder was observed in the Dialysis Room. This cylinder was in use by a resident at the time of the survey. The unsecured state of the cylinder was noted as a deficiency in the facility's adherence to safety regulations. The survey was conducted with the Maintenance Director, who acknowledged the finding during the tour. The unsecured oxygen cylinder was identified at 2:06 pm, highlighting a lapse in the facility's protocol for securing gas equipment. The observation was made in the presence of the Maintenance Director, ensuring that the deficiency was recognized by the facility's staff. The deficiency was further discussed and acknowledged by the Administrator during the exit conference. The report cites specific sections of the NFPA 101 and NFPA 99 standards that were not met, emphasizing the importance of proper storage and handling of gas equipment to ensure safety within the facility. The failure to secure the oxygen cylinder represents a breach in compliance with these safety standards.
Plan Of Correction
Responsible Party: The Director of Maintenance Immediate Action: Oxygen cylinder was secured upon identification. A facility wide audit was conducted to identify unsecured cylinder holders. Identification of Residents with potential to be affected: All in-house residents have potential to be affected. System Changes: All oxygen cylinder holders without a safety mechanism were removed from circulation. The safety mechanism was installed on those holders. Education for oxygen cylinder safety training was conducted with licensed staff. Upon identification of unsure holder, they must remove the holder from circulation and report to the Maintenance Department via Worx hub. Monitoring: Daily audits of all oxygen cylinder holders in storage areas to ensure all oxygen cylinder holders are secure prior to use. Results of the daily audit will be reported to Monthly Quality Assurance Performance Improvement Committee meeting for the next 90 days or until the committee agrees substantial compliance is met. Responsible Party: Director of Maintenance or designee
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Miami
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Dade Nursing And Rehabilitation Center | 3 mi | ★★★★★ | 5 | 0 |
| East Ridge Rehabilitation And Nursing Center | 3.2 mi | ★★★★★ | 5 | 0 |
| Coral Reef Subacute Care Center Llc | 3.3 mi | ★★★★★ | 1 | 0 |
| Jackson Memorial Perdue Medical Center | 3.6 mi | ★★★★★ | 5 | 0 |
| Kendall Lakes Healthcare And Rehab Center | 4.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.