St Annes Nursing Center, St Annes Residence Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Miami, Florida.
- Location
- 11855 Quail Roost Drive, Miami, Florida 33177
- CMS Provider Number
- 105560
- Inspections on file
- 25
- Latest survey
- November 13, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at St Annes Nursing Center, St Annes Residence Inc during CMS and state inspections, most recent first.
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 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
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
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