Surrey Place Healthcare And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Bradenton, Florida.
- Location
- 5525 21st Ave W, Bradenton, Florida 34209
- CMS Provider Number
- 105629
- Inspections on file
- 15
- Latest survey
- March 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Surrey Place Healthcare And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to meet state-mandated staffing requirements, with CNA hours falling below the 2.0 minimum on two occasions and weekly averages below 3.6 for eight weeks. Errors in staffing records and reliance on a non-compliant corporate form contributed to the deficiency. Interviews revealed a lack of formal training for the staffing coordinator and inconsistencies in recording staffing hours.
The facility failed to ensure proper hygiene in the kitchen, with staff not washing hands or changing gloves between handling soiled and clean dishes. Additionally, a resident was found with rotten fruit on her bedside table, which staff did not remove despite facility policies requiring the disposal of perishable foods. The Dietary Manager and Director of Nursing acknowledged these issues but did not take corrective action during the observations.
The facility failed to provide bed-hold notices during transfers for three residents. A resident was sent to the ER without a documented bed-hold notice, despite the policy being in the admission agreement. Another resident transferred for a procedure also lacked a documented notice, with the Social Services Director admitting to verbal notifications without documentation. A third resident transferred due to a condition change had no bed-hold notice recorded, with the Nursing Home Administrator acknowledging the need to review the notification process.
A resident was not provided with her physician-ordered hearing aids, leading to difficulty hearing. Staff interviews revealed that a CNA did not put in the hearing aids, and an RN failed to verify their use before signing off on the treatment record. The DON emphasized the expectation for nurses to ensure orders are completed.
Two residents in an LTC facility were observed with their catheter bags and tubing improperly positioned, dragging on the floor, which posed potential risks for accidents and infections. Despite care plans and facility policies requiring proper positioning, staff failed to consistently address the issue, leading to a deficiency in providing adequate care.
The facility failed to provide timely and complete Nursing Home Transfer and Discharge Notices for residents transferred to acute care facilities. In emergencies, notices were often completed after the resident's return, lacking necessary explanations and representative information. The Social Service Director admitted to delays and incomplete documentation, contrary to facility policy requiring written notice of transfer reasons.
The facility failed to provide timely transfer notices for two residents transferred to acute care facilities. One resident was transferred due to a change in condition, and the other for a medical procedure. Notices were completed post-transfer, lacking required information and timely delivery, indicating non-compliance with federal regulations.
The facility failed to ensure accurate Level I PASRR screenings for two residents prior to admission. One resident was admitted with mental health diagnoses not reflected in the initial PASRR screen, while another resident's PASRR screen did not indicate the presence of serious mental illness, leading to a missed Level II evaluation. Interviews revealed that PASRR screenings were often inaccurate from hospitals, and the facility lacked a PASRR policy.
Two residents in an LTC facility were observed with urinary catheter bags and tubing touching the floor, creating potential safety hazards. Despite having care plans and orders for catheter use due to urinary retention, the facility failed to ensure proper positioning of the equipment. Staff, including RNs and CNAs, confirmed awareness of the issue but did not consistently address it, contrary to the facility's policy.
A facility failed to accurately document a resident's clinical record when the resident was not present. Despite being transferred to an acute care facility, a Daily Medicare Nursing Note was recorded, detailing a physical assessment. Interviews with staff revealed inconsistencies, with an LPN acknowledging a potential mistake and the ADON confirming the resident's discharge. The facility's documentation policy emphasizes accuracy, which was not met in this instance.
During a facility tour, it was observed that an exit door in the therapy gym was not latching properly, failing to meet NFPA 101 (2012 Edition) standards. This was confirmed by facility maintenance staff.
Failure to Maintain Minimum Staffing Requirements
Penalty
Summary
The facility failed to maintain the minimum staffing requirements as mandated by state regulations. Specifically, the facility did not meet the required 2.0 direct care hours by certified nursing assistants (CNAs) on two occasions out of ninety-two days. Additionally, the facility failed to maintain a weekly average of 3.6 direct care hours per resident for eight out of fourteen weeks during the survey period. The discrepancies were identified through a review of the facility's staffing records, which showed incorrect calculations and inconsistencies in the reported staffing hours. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) provided multiple copies of staffing records, which contained errors and corrections. The initial records did not include weekly averages, and subsequent records showed incorrect calculations of CNA and nursing hours. Interviews with the staffing coordinator revealed that the facility did not use the state form for recording staffing hours but relied on a corporate Key Factor form, which did not accurately reflect the weekly averages required by state regulations. The staffing coordinator admitted to learning the role without formal training and acknowledged issues with call-offs affecting staffing levels. Further interviews with the Assistant Business Office Manager (ABOM) and the staffing coordinator highlighted a lack of clarity and consistency in recording and reporting staffing hours. The ABOM, new to payroll, relied on instructions from the NHA and the staffing coordinator to adjust hours to meet state requirements. The facility's assessment indicated a reliance on a formula to determine staffing needs, but the actual staffing levels fluctuated and occasionally fell below the state minimum requirements. The facility's failure to maintain accurate and compliant staffing records contributed to the deficiency identified during the survey.
Plan Of Correction
The Certified Nursing Assistant's (CNA) Per Patient Day for the specific dates were reviewed. No actions warranted due to the time has passed. The weekly direct care staffing hours for the specific weeks of /24, /24, /24 and for the quarter of through for meeting the weekly direct care average of 3.6 per patient day staffing requirement were reviewed. No actions are warranted due to the time has passed. An audit was conducted on the other 6 weeks which are /24, and for the Quarter through for meeting the minimum staffing requirements of 2.0 per patient day daily for Certified Nursing Assistants and the weekly average of direct care staffing of 3.60 per patient day. The results of the audit found that there were no other days during that specific quarter that the daily Certified Nursing Assistant staffing or the weekly average of direct care staffing did not meet the minimum staffing requirement of 2.0 per patient day and 3.6 per patient day respectively. On the Administrator initiated education for the Director of Nursing, Staffing Coordinator, Business Office Manager, Assistant Business Office Manager/Payroll, Rehab Director and the Activity Director related to meeting the daily minimum staffing for Certified Nursing Assistants of 2.0 per patient day and the definition of direct care staffing and meeting the required minimum weekly average of the 3.6 per patient day for direct care staff. Education was completed by The Director of Nursing/designee will audit the Certified Nursing Assistant staffing and direct care staffing 5 times per week for 12 weeks to ensure that the facility is meeting the Certified Nursing Assistant and direct care staffing requirements. The Director of Nursing/designee will review the audits with the monthly Quality Assurance Performance Improvement (QAPI) Committee for three months. The Quality Assurance Performance Improvement Committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.
Deficiencies in Kitchen Hygiene and Food Storage Practices
Penalty
Summary
The facility failed to ensure proper hygiene practices were followed by staff working in the kitchen, specifically in the dishwashing area. Observations revealed that staff members handling soiled dishes did not wash their hands or change gloves before handling clean and sanitized dishes. This was observed on multiple occasions over several days, with staff members moving directly from handling soiled items to clean items without appropriate hand hygiene. The Dietary Manager was present during some of these observations but did not intervene to correct the staff's actions. Additionally, the facility did not adhere to proper food safety and storage procedures for a resident. The resident was observed with rotten fruit on her bedside table for two days, which she intended to eat later. The Director of Nursing acknowledged that the resident was difficult and did not allow staff to remove the food, but stated that the staff should have reported the situation to a nurse or to her. The facility's policy requires nursing staff to discard perishable foods within three days or before the expiration date, and to discard any food showing signs of potential foodborne danger. The facility's policies on dishwashing and handwashing were not followed, as evidenced by the lack of handwashing between handling soiled and clean dishes. The Dietary Manager provided policies that outlined the need for maintaining dishwashing machines in a clean condition and for staff to practice good handwashing to minimize the risk of foodborne illness. However, these policies were not adhered to during the observed incidents, contributing to the deficiencies noted in the report.
Plan Of Correction
On the Certified Dietary Manager (CDM) provided education to the identified dietary staff on proper hygiene when working in the dish room with dirty/soiled and clean dishes. This included proper glove use and washing before putting gloves on or after taking gloves off. The Certified Dietary Manager (CDM) initiated education on hygiene and proper glove use with the other dietary staff. In addition, dietary staff were provided information about the dish machine that included the facility has a low temperature, chemical sanitizing dish machine. The education was completed by The Registered Dietician reviewed and provided input for updates related to the facility policy for Handwashing for Dietary Staff. The Certified Dietary Manager/designee is doing a minimum of 3 observations per week for 12 weeks related to dietary staff hygiene compliance when they are working with dirty/soiled dishes and clean dishes while in the dish room. The Certified Dietary Manager/designee will review the observations with the monthly Quality Assurance Performance Improvement (QAPI) Committee for three months. The Quality Assurance Performance Improvement committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee. On , Resident #14 was assessed for any potentially hazardous food at bedside. No adverse effects noted. On , all resident rooms were assessed to ensure that there was no potentially hazardous food at bedside. No additional areas of concern identified. On , the current policy related to Storage of Foods Brought to Residents by Family/visitors was reviewed and updated. The Director of Nursing (DON)/designee initiated education for Department Heads, nursing, and housekeeping staff related to food storage at bedside/in the resident room. The education was completed by The Director of Nursing/designee will complete 10 observations each week for 12 weeks to ensure that there is no potentially hazardous food being stored at bedside in a resident's room. The Director of Nursing/designee will review the audits with the monthly Quality Assurance Performance Improvement (QAPI) Committee for three months. The Quality Assurance Performance Improvement committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.
Failure to Provide Bed-Hold Notices During Resident Transfers
Penalty
Summary
The facility failed to provide a bed-hold notice at the time of transfer for three residents who were hospitalized. For Resident #55, the nursing notes indicated a transfer to the Emergency Room for evaluation following an incident, but there was no documentation of a bed-hold notice being provided to the resident or their representative. Although the facility's Admission and Financial Agreement, signed by the resident's family member, described the bed-hold policy, there was no evidence of notification at the time of transfer. Similarly, Resident #60 was transferred to an acute care facility for a medical procedure, but the facility's records did not include a bed-hold notice given to the resident's representative. The Social Services Director admitted to making phone calls to families regarding bed-hold options but did not document these notifications. For Resident #11, who was transferred to a hospital due to a change in condition, there was also no record of a bed-hold notice. The Nursing Home Administrator acknowledged that residents receive the bed-hold policy upon admission and stated that they would review the process with the Social Services Director to ensure proper documentation.
Plan Of Correction
The facility is unable to provide residents #55, #60 and #11 the bed hold notice at the time of their transfer to the hospital since the date of their discharge has passed. Residents #55, #60 and #11 were re-admitted and/or returned to the facility after their emergency discharge to the hospital. Other residents discharged after with a need for an unplanned/emergent transfer/discharge will receive a bed hold form as noted in the facility Bed Hold policy. The facility policy for Bed Hold has been reviewed. On [date], the Director of Nursing/designee initiated education for the nurses, Assistant Director of Nursing, Social Service Director, and Medical Records related to the Bed Hold policy. This education was completed by [date]. The Social Service Director/designee will do a weekly audit for 12 weeks on a minimum of 3 unplanned/emergent transferred residents and/or residents on a therapeutic leave each week. Otherwise, if the facility doesn't have at least 3 unplanned/emergent transferred residents and/or residents on a therapeutic leave for that week, the Social Service Director/designee will complete the weekly audit on the number of transferred/on leave residents that the facility has for that week. This weekly audit will be done to ensure that the facility provided transferred residents written notice on the facility Bed Hold policy for residents who were transferred for hospitalization or those on a therapeutic leave. The Social Services Director/designee will review the audits with the monthly Quality Assurance Performance Improvement Committee for three months. The Quality Assurance Performance Improvement Committee will evaluate the outcome of the audits and, if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.
Failure to Follow Physician Orders for Hearing Aids
Penalty
Summary
The facility failed to follow physician orders for a resident who required an assistive hearing device. Observations and interviews revealed that the resident was not provided with her hearing aids when she was assisted out of bed, despite having a physician's order to wear them during the day. The resident expressed difficulty hearing because the staff did not put in her hearing aids as required. Interviews with staff members, including a CNA and an RN, indicated a lack of adherence to the physician's order. The CNA admitted to not putting in the resident's hearing aids, while the RN assumed the CNA had done so without verifying. The Director of Nurses stated that nurses are expected to ensure orders are completed before signing off on treatment records, which was not done in this case.
Plan Of Correction
On the were provided to resident #16 and placed in her. On for resident #16, the Director of Nursing (DON) completed a Medication error Reporting Form. On, all other resident records were checked; there were no other residents with a physician ordered assistive device for hearing. On the Director of Nursing/designee provided education to the direct care nurse for resident #16 on adherence and documentation related to physician ordered assistive devices for hearing. On, the Director of Nursing/designee provided education to the other nurses on adherence and documentation related to physician ordered assistive devices for hearing. The education was completed by. The Director of Nursing/designee will complete 3 audits each week for 12 weeks to ensure physician ordered assistive devices for hearing are placed in the resident's prior to the nurse signing the administration record. The Director of Nursing/designee will review the audits with the monthly Quality Assurance Performance Improvement (QAPI) Committee for three months. The Quality Assurance Performance Improvement committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.
Improper Positioning of Catheter Bags and Tubing
Penalty
Summary
The facility failed to provide adequate care and services to prevent injuries for two residents who were observed with their catheter bags and tubing improperly positioned. Resident #123 was seen with her catheter bag and tubing dragging on the floor while she was seated in her wheelchair, posing a potential risk for accidents and infection. The resident's medical records indicated she had a history of retention and was using a catheter, which was supposed to be positioned off the floor according to her care plan. However, the nursing staff, including Staff E, RN, were unaware of the improper positioning of the catheter bag and tubing. Similarly, Resident #124 was observed with her catheter bag and tubing touching the floor on multiple occasions. The tubing was seen in excess tension and was even run over by the wheelchair tires when a visitor repositioned the resident. Resident #124's medical records showed a history of retention and the use of a catheter, with care plans specifying the need for proper positioning of the catheter bag and tubing. Despite these care plans, the staff, including CNAs Staff F and G, confirmed they had observed the improper positioning but did not consistently address it. Interviews with the Director and the Director of Nursing revealed that they were not aware of the issues with the catheter bags and tubing touching the floor. The facility's policy on catheter care emphasized the importance of securing the tubing and positioning the drainage bag off the floor, yet this was not adhered to in practice. The failure to follow these procedures led to the deficiency in providing adequate and appropriate health care to the residents involved.
Plan Of Correction
On the for resident #123 was positioned and secured properly so the bag nor the tubing touched the floor. On the for resident #124 was positioned and secured properly so the bag nor the tubing touched the floor. On , all other residents identified with were checked for proper positioning and securing so the bag nor the tubing of the touched the floor. For these other residents, no area of concern identified. On the Director of Nursing (DON)/designee initiated education for nurses, certified nursing assistants and staff related to proper positioning and securing of bags/tubing. Education completed by The Director of Nursing/designee for all residents with will do an audit 2 times a week for 12 weeks to ensure proper positioning and securing the tubing for those residents with so no bag or tubing for are touching the floor. The Director of Nursing/designee will review the audits with the monthly Quality Assurance Performance Improvement (QAPI) Committee for three months. The Quality Assurance Performance Improvement committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.
Deficiencies in Transfer and Discharge Notice Procedures
Penalty
Summary
The report identifies deficiencies in the handling of Nursing Home Transfer and Discharge Notices for residents being transferred to acute care facilities. Specifically, the facility failed to provide timely and complete discharge notices to residents and their representatives. In the case of Resident #11, the notice was signed by the Social Service Director (SSD) and the resident, but the Nursing Home Administrator expressed uncertainty about how residents could sign the notice during emergency transfers. Similarly, for Resident #60, the notice lacked a brief explanation to support the transfer action and did not include resident representative information. The SSD admitted that notices were often completed after the resident returned from the hospital, due to the emergency nature of the transfers. The facility's policy on transfer and discharge requires that residents and their representatives be notified in writing of the reasons for transfer or discharge. However, the SSD acknowledged that in 9 out of 10 cases, the transfer was an emergency, and the resident or family was not present to sign the notice. The SSD also mentioned that the notices were typically uploaded into resident records but might still be in the office. The facility's policy allows for immediate notice in cases where the resident's urgent medical needs require a transfer, but the report indicates that the facility did not consistently adhere to this policy, resulting in incomplete and delayed notifications.
Plan Of Correction
Do a weekly audit for 12 weeks on a minimum of 3 discharged residents each week. Otherwise, if the facility doesn't have at least 3 discharges per week, the Social Service Director/designee will complete the weekly audit on the number of discharges the facility has for that week. This weekly audit will be done to ensure that the facility provided discharged residents the Nursing Home Transfer and Discharge Notice form per the facility policy. The Social Service Director or designee will review the audits with the monthly Quality Assurance Performance Improvement Committee for three months. The Quality Assurance and Performance Improvement Committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.
Failure to Provide Timely Transfer Notices
Penalty
Summary
The facility failed to provide proper notice of transfer before initiating a transfer for two residents, which is a violation of the regulatory requirements. Resident #11 was admitted with multiple diagnoses, including acute failure, and experienced a change in condition that led to a recommendation for hospital transfer. The facility issued a Nursing Home Transfer and Discharge Notice after the transfer, which was signed by the Social Service Director and the resident post-transfer, indicating a lack of timely notification. Resident #60 was transferred to an acute care facility for a medical procedure, but the Nursing Home Transfer and Discharge Notice was not completed with all required information. The notice lacked a brief explanation to support the transfer action and did not include the resident representative's information. The notice was signed by the resident after the transfer, which suggests that the facility did not provide the notice in advance as required. Interviews with facility staff, including the Nursing Home Administrator and the Social Services Director, revealed a misunderstanding or misapplication of the notice requirements, particularly in emergency situations. The facility's policy on transfer and discharge notice was not followed, as evidenced by the delayed completion and signing of the notices. This deficiency highlights the facility's failure to adhere to federal regulations regarding timely and complete notification of transfers or discharges.
Plan Of Correction
The facility is unable to have residents #55, #60 and #11 sign the Nursing Home Transfer and Discharge Notice at the time of discharge to the hospital since the date of their discharge has passed. Residents #55, #60 and #11 were re-admitted and/or returned to the facility after their emergency discharge to the hospital. Other residents discharged after will receive the Nursing Home Transfer and Discharge Notice based on the facility policies. The facility policy for Notice of Transfer and/or Discharge was reviewed. On the Director of Nursing/designee initiated education for the nurses, Assistant Director of Nursing, Social Service Director and Medical records related to the facility Notice of Transfer and Discharge policy and Making an Emergency Transfer or Discharge policy. The education included the Nursing Home Transfer and Discharge Notice form. This education was completed by The Social Service Director/designee will do a weekly audit for 12 weeks on a minimum of 3 discharged residents each week. Otherwise, if the facility doesn't have at least 3 discharges per week, the Social Service Director/designee will complete the weekly audit on the number of discharges the facility has for that week. This weekly audit will be done to ensure that the facility provided discharged residents the Nursing Home Transfer and Discharge Notice form per the facility policy. The Social Service Director or designee will review the audits with the monthly Quality Assurance Performance Improvement Committee for three months. The Quality Assurance and Performance Improvement Committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.
Inaccurate PASRR Screenings for Two Residents
Penalty
Summary
The facility failed to ensure accurate Level I Preadmission Screening and Resident Review (PASRR) screenings for two residents prior to their admission. Resident #41 was admitted with diagnoses including adjustment disorder with mixed anxiety and depressed mood, and major depressive disorder. However, the initial Level I PASRR screen completed by a Licensed Clinical Social Worker at a hospital did not identify these mental illness diagnoses. A subsequent PASRR screen completed by a Registered Nurse at the facility also failed to include all necessary diagnoses, leading to an incomplete and inaccurate assessment. Resident #16 was admitted with diagnoses including major depressive disorder, recurrent, severe with psychotic symptoms, and unspecified anxiety disorder. The Level I PASRR screen for this resident did not accurately reflect the presence of serious mental illness, as it marked that no diagnosis or suspicion of serious mental illness was indicated. This oversight resulted in the resident not being flagged for a Level II PASRR evaluation, which is required for individuals with serious mental illness or intellectual disabilities. Interviews with the facility's MDS Coordinator and Director of Nursing (DON) revealed that the PASRR screenings were often inaccurate when received from hospitals, and there was no existing PASRR policy at the facility. The MDS Coordinator acknowledged the need for a Level II PASRR review for Resident #16 and confirmed that the facility's PASRR processes were not being conducted accurately, as evidenced by the incorrect screenings for both residents.
Plan Of Correction
A new Preadmission Screening and Resident Review (PASRR) was completed on 3/14/25 for resident #41 to include anxiety. On Resident #16, Preadmission Screening and Resident Review (PASRR) was re-evaluated by the Minimum Data Set (MDS) Coordinator, and a Level II Preadmission Screening and Resident Review (PASRR) was requested and submitted to the Florida Preadmission Screening and Resident Review Portal. The Minimum Data Set (MDS) Coordinator received a response from the Florida Preadmission Screening and Resident Review Portal on the outcome of the Level II request for resident #16, and it was denied. The Minimum Data Set (MDS) Coordinator initiated an audit of the Level I Preadmission Screening and Resident Reviews (PASRRs) for all current residents to ensure the Level I Preadmission Screening and Resident Reviews are correct based on each individual resident. Identified corrections were addressed, and the appropriate corrections were made. In addition, as noted in the Statement of Deficiency, the Minimum Data Set (MDS) Coordinator recently participated in a Webinar by the Florida Preadmission Screening and Resident Review Portal. This educational Webinar addressed proper completion for Level II Preadmission Screening and Resident Reviews (PASRRs). The education included the need for a Level II Preadmission Screening and Resident Review (PASRR) to be submitted for a resident. Education was provided by the Minimum Data Set (MDS) Coordinator to the Admissions team and RN Management staff related to Level I and Level II Preadmission Screening and Resident Reviews. The education was completed by the Minimum Data Set Coordinator/designee. The Minimum Data Set (MDS) Coordinator/designee is auditing a minimum of three Preadmission Screening and Resident Reviews (PASRRs) each week for 12 weeks to ensure that the admission Preadmission Screening and Resident Reviews are accurate and the follow-up related to Level II Preadmission Screening and Resident Reviews (PASRRs) are completed. The Minimum Data Set (MDS) Coordinator/designee will review the audits with the monthly Quality Assurance Performance Improvement Committee for three months. The Quality Assurance Performance Improvement Committee will evaluate the outcome of the audits and, if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.
Inadequate Catheter Care Leads to Safety Hazards
Penalty
Summary
The facility failed to provide adequate care and services to prevent injuries for two residents who utilized urinary catheters. Observations revealed that Resident #123 had a catheter bag and tubing hanging below the seat of her wheelchair, with portions touching the floor. This was observed while she was scooting back and forth in her wheelchair, creating a potential hazard. The resident's medical records indicated a diagnosis of urinary retention, and she had orders for a catheter. However, the care plan did not ensure the catheter bag and tubing were kept off the floor, as confirmed by the resident's nurse, Staff E, RN. Similarly, Resident #124 was observed with a catheter bag and tubing touching the floor while seated in her wheelchair. The tubing was in excess tension and was observed touching the front wheel of the wheelchair. The resident's medical records showed a history of urinary retention and orders for a catheter. Despite this, the care plan failed to ensure the catheter bag and tubing were properly positioned, as confirmed by Staff E, RN, and CNAs Staff F and Staff G. Both CNAs acknowledged observing the catheter equipment on the floor and stated that they could reposition it or report it to a nurse. The facility's Director of Nursing provided a policy for catheter care, which stated that the drainage bag should be secured in a manner that prevents it from touching the floor. However, the policy was not effectively implemented, as evidenced by the observations of the catheter bags and tubing on the floor for both residents. The Director of Rehabilitation also confirmed that her staff should ensure proper positioning of the catheter equipment but was unaware of the deficiencies observed with Residents #123 and #124.
Plan Of Correction
On the for resident #123 was positioned and secured properly so the bag nor the tubing touched the floor. On the for resident #124 was positioned and secured properly so the bag nor the tubing touched the floor. On all other residents identified with were checked for proper positioning and securing so the bag nor the tubing of the touched the floor. For these other residents, no area of concern identified. On the Director of Nursing (DON)/designee initiated education for nurses, certified nursing assistants and staff related to proper positioning and securing of bags/tubing. Education completed by The Director of Nursing/designee for all residents with will do an audit 2 times a week for 12 weeks to ensure proper positioning and securing the tubing for those residents with so no bag or tubing for are touching the floor. The Director of Nursing/designee will review the audits with the monthly Quality Assurance Performance Improvement (QAPI) Committee for three months. The Quality Assurance Performance Improvement committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.
Inaccurate Documentation of Resident Assessment
Penalty
Summary
The facility failed to accurately document in the clinical record for one resident, identified as Resident #60, during a time when the resident was not present in the facility. An observation noted that Resident #60 was sitting up in bed with a meal and did not appear to be in visible distress. However, a review of the Skilled Nursing Facility/Nursing Facility to Hospital Transfer form indicated that the resident had been transferred to an acute care facility for a procedure. Despite this, a Daily Medicare A/Managed Care Nursing Note was documented, detailing a physical assessment of the resident, which included various health metrics and observations, even though the resident was not in the facility at the time. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON), revealed inconsistencies in the documentation process. The LPN acknowledged that a mistake might have been made, as it was not typical to document on a discharged resident. The ADON confirmed that the resident had been discharged and should not have been documented on, except for a hospital follow-up note. The ADON also noted that the expectation was to assess and document accurately, indicating that the note in question was incorrect. The facility's policy on clinical documentation emphasized the need for accurate and timely entries that reflect the care and services provided to residents. The policy outlined the importance of maintaining a complete account of the resident's care, treatment, and response, as well as supporting quality medical care and legal records. However, the documentation for Resident #60 did not adhere to these standards, as it included an assessment for a resident who was not present in the facility, highlighting a lapse in the facility's documentation practices.
Plan Of Correction
The Director of Nursing (DON) interviewed the nurse who entered the incorrect documentation into the medical record for Resident #60 on [date], and then followed the facility policy for incorrect documentation and struck out the incorrect documentation for Resident #60 on [date]. On [date], the Director of Nursing/designee initiated an audit on other residents discharged from [date] to [date] and there were no other residents that had documentation after discharge. On [date], the Director of Nursing provided education to the facility per diem nurse that incorrectly documented on discharged resident #60. On [date], the Director of Nursing/designee initiated education for the other nurses related to accurate and complete resident documentation on current residents only. The education was completed by [date]. The Director of Nursing/designee will complete an audit a minimum of one time per week for 12 weeks. This weekly audit will be to review discharged residents for the week to ensure that there is no incorrect documentation entered after a resident has discharged. The Director of Nursing/designee will review the audits with the monthly Quality Assurance Performance Improvement (QAPI) Committee for three months. The Quality Assurance Performance Improvement committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.
Failure to Maintain Exit Door Latching in Therapy Gym
Penalty
Summary
The facility failed to maintain exit doors in accordance with NFPA 101 (2012 Edition) during a facility tour conducted on March 12, 2025, between 9:00 a.m. and 3:00 p.m. An exit door in the therapy gym was observed to be not latching properly. This observation was confirmed through an interview with facility maintenance staff who were present during the tour. The deficiency is cited under NFPA 101 (2012 Edition) sections 19.2.2.2.1, 7.2.1, 7.2.1.5.10, and 4.6.
Plan Of Correction
On 3/12/25 the Maintenance Director/Maintenance Assistance evaluated the Exit Door in the therapy gym and made adjustments to the door so it could latch properly. ATTACHMENT #55 See corresponding email sent to area office dated 4/4/25 with attachments. On 3/12/25 the Maintenance Director inspected the other Exit Doors to ensure that the exit doors close and latch properly. During this inspection, there were no other exit doors that did not close and latch properly. ATTACHMENT #56 See corresponding email sent to area office dated 4/4/25 with attachments. On 3/12/25, the Administrator provided an inservice for the Maintenance and Therapy staff on the importance for exit doors to close and latch properly. The inservice included notifying the administrator/designee of any exit doors that do not close and latch properly and a plan to correct as indicated. ATTACHMENT #57 See corresponding email sent to area office dated 4/4/25 with attachments. The facility Maintenance Director/designee will audit facility exit doors weekly to help monitor and maintain proper latching for the facility exit doors. The monthly audit of exit doors will be recorded on a log. ATTACHMENT #58 See corresponding email sent to area office dated 4/4/25 with attachments. The Maintenance Director/designee will provide the monthly QAPI Committee a summary report on the findings from the audits of the facility exit doors for three (3) months. The QAPI committee will evaluate the outcome of the audits and if necessary amend the improvement plan and continue to monitor until sustained improvement has been determined by the committee. ATTACHMENT #59 See corresponding email sent to area office dated 4/4/25 with attachments.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
