Terrace Of Kissimmee, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Kissimmee, Florida.
- Location
- 221 Park Place Blvd, Kissimmee, Florida 34741
- CMS Provider Number
- 105839
- Inspections on file
- 31
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Terrace Of Kissimmee, The during CMS and state inspections, most recent first.
A resident with multiple health conditions experienced a fall resulting in significant injuries, including fractures and a subdural hematoma. The discharge MDS assessment failed to accurately reflect these injuries, instead documenting a fall with no injury. Staff interviews confirmed the assessment was inaccurate and did not align with the resident's medical record.
A resident on hospice care experienced a fall resulting in injury and was transferred to the hospital. Although the care plan and facility agreement required notification of the hospice provider for any significant change in condition, documentation and interviews confirmed that hospice was not informed of the incident or hospital transfer. The DON acknowledged this lapse in required communication.
Surveyors found that the facility did not consistently label, date, or discard food items as required, with multiple unlabeled, undated, and expired foods stored in the kitchen, refrigerator, and freezer. Food and beverage items were also stored directly on the floor, and cups and glasses were not air-dried before use, but instead dried with towels or served wet. Staff interviews confirmed a lack of adherence to food safety protocols, and facility policies regarding food storage and handling were not followed.
The facility received repeat deficiencies for infection control and medication administration due to insufficient auditing and oversight by the QAPI committee. Despite having a QAPI program, the committee did not adequately monitor or review previously identified problem areas, resulting in recurring citations.
A nurse left medication cups containing multiple prescribed pills at the bedside of a resident with Parkinson's disease and other conditions, allowing the resident's spouse to administer the medications during a meal. The nurse and supervisory staff confirmed that this practice was not in accordance with facility policy, which requires licensed staff to administer and document medications.
The facility did not ensure accurate MDS assessments for two residents, resulting in the omission of oxygen therapy and tobacco use for a resident with chronic respiratory failure and smoking history, and the incorrect coding of an active psychotic disorder for another resident without such a diagnosis. These errors were confirmed through record review, observation, and staff interviews.
The facility did not ensure accurate Level I PASARR assessments for two residents with mental health diagnoses, omitting key psychiatric conditions from their screenings despite evidence in their medical records and care plans. Staff interviews confirmed that the process for reviewing and updating PASARRs was ineffective, leading to incomplete documentation and unaddressed needs.
A resident with a history of anemia and end stage renal disease was admitted with chest dressings covering a Permacath site and a chemoport. Facility staff did not obtain a physician's order for the care or removal of these dressings, and nursing staff confirmed they had not changed or removed them since admission, nor had guidance on their management.
A resident admitted with a urinary catheter and acute UTI did not receive timely assessment or follow-up for catheter removal, including the required urology consult. Facility staff confirmed that no urology appointment was scheduled and no interventions for catheter removal were attempted, despite discharge instructions and facility protocol.
A resident with severe cognitive impairment and multiple health conditions experienced significant weight loss that was not addressed for over three weeks. Despite documented weight loss and a care plan goal to prevent it, the facility did not promptly notify the RD or discuss the case in weekly care meetings, resulting in a lack of timely intervention.
Staff did not offer hand hygiene to residents before meals, contrary to facility policy, and a resident with a urinary catheter was observed with the drainage bag dragging on the floor and scraping against the wheelchair wheel. Staff interviews and observations confirmed these lapses in infection control practices.
A resident with moderate cognitive impairment and incontinence was found in a urine-soaked bed, indicating neglect due to inadequate incontinence care during the night and early morning shifts. The night shift CNA failed to conduct walking rounds or provide a report to the day shift CNA, leading to a lack of communication and continuity of care. The facility's documentation was also lacking, with no progress notes or records of care refusal, contributing to the deficiency.
A resident with moderate cognitive impairment was found in a urine-soaked bed with long, dirty fingernails and unshaved facial hair, indicating a failure in providing adequate ADL care. The resident reported not receiving incontinence care during the night or day shifts, and staff confirmed the lack of care due to being occupied with other tasks. The facility's policy required re-approaching residents who resist care, but this was not followed, leading to the deficiency.
A resident with skin conditions was improperly administered Triamcinolone Acetonide cream by a CNA, following an LPN's instruction, contrary to physician orders and facility policy. The cream was applied to areas not specified in the order, and the facility's policy mandates that only licensed personnel administer medications.
A resident with a Full Code status was found not breathing, but the facility staff failed to initiate CPR or verify the code status. The LPN and RN involved did not follow protocols, resulting in neglect of the resident's advanced directives and physician's orders.
A resident with a Full Code status was found unresponsive in a facility, but staff failed to initiate CPR as required by the resident's advance directives and physician's orders. Despite being informed of the resident's condition, both the LPN and RN Supervisor did not verify the code status or perform resuscitation, leading to the resident being pronounced dead without any life-saving measures attempted.
A resident on hospice with a Full Code order was found without vital signs, but staff failed to perform CPR or report the neglect immediately. The LPN and RN involved did not check the resident's code status, and the RN did not inform the ADON about the failure to perform CPR. The facility's policies required immediate reporting of neglect, which was not followed.
Two residents with significant mobility impairments were found with their call bells out of reach, despite care plans specifying they should be accessible. Observations confirmed the call bells were on the floor, and staff verified the oversight, leading to a deficiency in accommodating residents' needs.
A resident with severe cognitive impairment and physical limitations did not receive necessary nail and oral care services. Observations showed overgrown and soiled nails and significant oral debris. Despite occasional refusals, there was inadequate documentation of care provided or refusals communicated to family or physicians, highlighting a deficiency in maintaining the resident's hygiene.
The facility failed to promote dignity in dining for a resident with Alzheimer's disease, dementia, and legal blindness. CNAs were observed standing while feeding the resident, against policy, and staff referred to residents needing assistance as 'Feeders,' which is also against policy.
Inaccurate MDS Assessment Following Resident Fall with Injury
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's health conditions following a fall. A resident with multiple diagnoses, including seizures, muscle weakness, and dementia, experienced a fall resulting in bleeding from the nose, a skin tear above the eyebrow, and was subsequently transferred to the hospital. Hospital records documented significant injuries, including a subdural hematoma, nasal bone fractures, a right femoral neck fracture, and other facial injuries. However, the discharge MDS assessment completed with an Assessment Reference Date (ARD) on the day of the fall indicated only one fall with no injury since admission or prior assessment. Interviews with the MDS Coordinator, DON, and Regional MDS Nurse confirmed that the discharge MDS assessment was inaccurate, as it did not capture the injuries sustained by the resident during the fall. The staff acknowledged that the assessment should have reflected the injuries, but the MDS was completed before all injury information was known. The facility's policy requires that MDS assessments accurately reflect information in the medical record, but this was not followed in this instance.
Failure to Notify Hospice Provider After Resident Fall and Hospital Transfer
Penalty
Summary
The facility failed to communicate with the hospice provider when a change in condition was identified for a resident receiving hospice services. The resident, who had multiple diagnoses including seizures, bone disorders, anxiety, muscle weakness, and dementia with mood disturbance, was readmitted to the facility from an acute care hospital on hospice care. The resident's care plan required staff to notify the nurse, physician, and hospice provider of any noted changes in condition. On the date of the incident, the resident experienced a fall resulting in a nosebleed and a skin tear, and was subsequently transferred to the hospital. Documentation showed that the physician and family were notified, but there was no evidence that the hospice provider was informed of the fall or the hospital transfer. Interviews confirmed that the hospice provider was not notified of the resident's change in condition or transfer, and the DON acknowledged that hospice should have been informed and that such notification should have been documented. The facility's agreement with the hospice provider required immediate notification of any significant change in a hospice patient's status, including the need for hospital transfer. The lack of communication with hospice following the resident's fall and transfer constituted a failure to ensure collaboration on the provision of necessary care and services.
Failure to Properly Store, Label, and Handle Food and Food Service Items
Penalty
Summary
The facility failed to store, label, date, and discard food items in accordance with professional standards for food service safety. During a kitchen tour, multiple leftover and previously opened food items were found in the walk-in refrigerator without labels or dates, including various cheeses, meats, and prepared dishes. Several items were also found with expired dates, and raw meats were stored longer than recommended. Additionally, some food items and unopened cases were stored directly on the floor in both the refrigerator and freezer, contrary to facility policy. There was no signage in the kitchen to reference acceptable storage periods for perishable foods. In the dish machine area, trays of plastic drinking glasses and coffee cups were observed sitting inverted on wet trays, and dietary staff reported drying them with towels rather than allowing them to air-dry, which does not meet sanitary standards. During meal service, residents were served beverages in glasses and cups that had been transported and served from wet trays, with the lips of the cups in contact with water. In the dry storage room, a container without a handle was used as a scoop in a bin of sugar, and several food items were stored on the floor, further violating storage protocols. Interviews with dietary staff and management confirmed that all kitchen staff were responsible for labeling and dating foods, and acknowledged the importance of these practices for food safety. However, the staff admitted that these procedures were not consistently followed. In the nourishment room, previously opened and undated nutrition supplements and thickened juice were found, and nursing staff were unsure of the appropriate timeframes for use after opening. Facility policies required food to be labeled, dated, and stored off the floor, but these standards were not met in multiple areas.
Repeat Deficiencies Due to Inadequate QAPI Monitoring and Oversight
Penalty
Summary
The facility failed to implement its Quality Assurance and Performance Improvement (QAPI) policies to ensure thorough monitoring and tracking of previously identified areas of concern. Specifically, the facility did not adequately audit or oversee issues related to infection control and medication administration, which had previously resulted in deficiencies at F880 and F554. Despite having a QAPI program in place that outlined the need for organized data collection and evaluation of state survey deficiencies, the facility did not sustain improvements or prevent repeat citations in these areas. During the survey, it was found that the QAPI committee did not sufficiently implement, monitor, or review the identified problem areas, leading to repeat deficiencies. The administrator acknowledged that while medication-related audits were performed, no recent trends were identified, and the committee's oversight was insufficient to prevent recurrence of the same issues. No specific resident details or medical histories were provided in the report.
Medications Left at Bedside for Unlicensed Administration
Penalty
Summary
A deficiency occurred when a nurse left two medication cups containing multiple pills, including Tylenol, Parkinson's medication, antihistamine, neuropathy medication, stool softener, and laxative, on the overbed table of a male resident with Parkinson's disease, peripheral neuropathy, mixed anxiety disorders, and neuralgia. The resident's spouse was observed assisting with lunch and stated that the nurse routinely left medications for her to administer with the meal. The nurse confirmed she had left the medications with the spouse, and the unit manager and Director of Nursing both acknowledged that medications should not be left at the bedside and should be administered by licensed staff. Facility policy requires that only licensed or permitted individuals prepare, administer, and document medication administration.
Inaccurate MDS Assessments for Oxygen Use, Tobacco Use, and Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the clinical status and care needs of residents. For one resident with chronic obstructive pulmonary disease, diabetes, and chronic respiratory failure who was dependent on supplemental oxygen, the admission MDS did not indicate the use of oxygen therapy in Section O, despite clear documentation in the medical record, physician orders, and direct observation of oxygen use. Additionally, this same resident was identified as a smoker through medical records, physician orders, and direct observation, but Section J of the MDS incorrectly indicated that the resident was not a tobacco user. The MDS Lead acknowledged these inaccuracies and confirmed that the assessment should have captured both oxygen and tobacco use. Another resident was incorrectly coded in the MDS as having an active psychotic disorder other than schizophrenia, even though there was no such diagnosis documented in the medical record. The Director of Nursing confirmed the absence of this diagnosis. The RAI manual specifies that only physician-documented diagnoses with a direct relationship to the resident's current status should be coded as active. These inaccuracies in the MDS assessments were identified through observation, interview, and record review.
Failure to Complete Accurate PASARR Assessments for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that individuals with mental disorders, intellectual disabilities, or related conditions had accurate Level I Preadmission Screening and Resident Reviews (PASARR) completed upon admission and updated as needed. For two residents, the Level I PASARR assessments did not include all relevant psychiatric diagnoses, such as anxiety, depression, and bipolar disorder, despite these conditions being documented in their medical records and reflected in their medication orders and care plans. In one case, a resident with multiple psychiatric diagnoses and behaviors was admitted with a PASARR that omitted these diagnoses, and the need for a Level II PASARR assessment was not determined. In another case, a resident with depressive episodes and anxiety was admitted with a PASARR that did not reflect her psychiatric conditions, even though her behaviors and medication use indicated active mental health concerns. Interviews with facility staff revealed that the process for reviewing and updating PASARR documentation was not consistently effective. The interdisciplinary team reviewed PASARRs within 24 hours of admission, and the MDS staff was responsible for quarterly reviews, but discrepancies in psychiatric diagnoses were not identified or addressed. The facility's policy required screening for mental and related disorders and referral for further assessment as needed, but this process was not followed in these cases, resulting in incomplete PASARR documentation and potential gaps in care planning.
Failure to Obtain Physician's Order for Catheter Dressing Care
Penalty
Summary
The facility failed to obtain a physician's order for the care and treatment of catheter dressings for a resident with a history of iron deficiency anemia, end stage renal disease, and recent hospitalization. Upon admission, the resident had a surgical wound from a right chest Permacath and a chemoport on the left upper clavicle, both covered with dressings. During interviews and record reviews, it was found that neither dressing was marked with initials or dates, and the resident reported that staff had not changed or removed either dressing since admission. Nursing staff, including a registered nurse and the North Unit Manager, confirmed there were no physician's orders regarding the management of the dressings on the resident's chest. The North Unit Manager recalled that the dressings were to remain in place until a specialty appointment but was unable to locate any physician's order to that effect. This lack of a physician's order meant that nursing staff did not have guidance on whether or how to provide care for the resident's chest dressings.
Failure to Ensure Timely Urology Follow-Up and Catheter Assessment
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely assessment and follow-up for the removal of an indwelling urinary catheter for a resident admitted with a diagnosis of acute urinary tract infection and urinary retention. The hospital discharge paperwork specified that the urinary catheter, placed prior to admission, needed to be changed every 30 days and that a follow-up appointment with a urology specialist was required. Despite these instructions, there was no documentation in the resident's medical record indicating that a urology consult had been scheduled or that any interventions for catheter removal, such as intermittent catheterization, had been attempted since admission. Interviews with facility staff, including the DON and the Scheduler, confirmed that no urology consults had been scheduled and no actions had been taken to address the removal of the catheter. The DON stated that the APRN had advised against removing the catheter until a urology consultation occurred, but attempts to contact the APRN were unsuccessful. Review of the facility's clinical protocol indicated that evaluation for catheter removal should have been performed, but this was not documented or carried out for the resident.
Failure to Address Significant Weight Loss
Penalty
Summary
A resident with severe cognitive impairment, aphasia, dysphagia, and dementia experienced significant, unaddressed weight loss over a period of several weeks. The resident's medical record showed an 8% weight loss in one week and an 11.5% loss over 90 days, but there was no evidence that this significant weight loss was addressed for over three weeks. The resident was not on a physician-prescribed weight loss prevention regimen, and the care plan indicated a goal to prevent significant weight loss, which was not met. Interviews and record reviews revealed that the facility's process for monitoring and responding to weight loss was inadequate. The Registered Dietician (RD) was not notified promptly of the resident's weight loss, and the Certified Dietary Manager (CDM) did not bring the resident's case to the Standards of Care meetings. The facility relied on periodic percentage-based reviews rather than timely responses to actual weight changes, resulting in a lack of intervention despite ongoing weight loss. The facility's policy required multidisciplinary assessment and intervention, but this was not followed in the resident's case.
Failure to Provide Hand Hygiene and Proper Catheter Bag Management
Penalty
Summary
The facility failed to implement effective infection prevention and control practices as evidenced by the lack of hand hygiene offered to residents prior to meals and improper management of a urinary catheter drainage bag. During multiple dining observations, staff did not offer hand hygiene to residents before meals, despite the facility's policy requiring assistance with hand hygiene before eating. Staff interviews confirmed that hand hygiene was not routinely provided, and both residents and visitors reported not being offered hand hygiene before meals. The Infection Control nurse acknowledged the lapse and noted that individualized hand wipes were not provided as intended. Additionally, a resident with a urinary catheter was observed on several occasions with the catheter drainage bag dragging on the floor and scraping against the wheelchair wheel. Staff, including the Infection Preventionist, did not intervene to correct the situation. The facility's policy on catheter-associated urinary tract infections specifies that catheter drainage bags should not be placed on the floor, a guideline that was not followed in this instance. The Director of Nursing and Regional Nurse Consultant confirmed that proper catheter bag management was not maintained.
Neglect Due to Inadequate Incontinence Care and Shift Handover
Penalty
Summary
The facility failed to provide necessary care and services to a resident, leading to a deficiency in preventing neglect. A male resident, who was moderately cognitively impaired and incontinent, was found in a urine-soaked bed, indicating a lack of incontinence care during the night and early morning shifts. The resident reported not being changed since the previous day, and the CNA assigned to him during the day shift confirmed the resident's condition upon her arrival. The deficiency was further compounded by a lack of communication and proper handover between the night and day shift CNAs. The night shift CNA did not conduct walking rounds or provide a report to the incoming day shift CNA, leading to a failure in identifying and addressing the resident's care needs. The DON confirmed that the expected protocol of conducting walking rounds and providing incontinence care every two hours was not followed. Additionally, the facility's documentation practices were inadequate, as there were no nursing progress notes for several days, and no documentation of the resident refusing care. The DON and other staff acknowledged the importance of following care plans and conducting shift change rounds, but these practices were not adhered to, resulting in the resident's neglect.
Failure to Provide Adequate ADL Care for a Resident
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for a dependent resident, specifically in the areas of incontinence care, fingernail care, and shaving facial hair. The resident, a male with moderate cognitive impairment, was found in a urine-soaked bed with long, dirty fingernails and unshaved facial hair. The resident reported that his brief had not been changed during the overnight shift or since the start of the day shift, and he had not received nail care or shaving for an extended period. The resident's care plan indicated he was at risk for functional incontinence and required staff assistance with ADLs to remain clean, dry, and odor-free. However, observations revealed that the resident's care needs were not met, as evidenced by the strong odor of urine in his room and his unkempt appearance. The assigned CNA for the day shift confirmed she had not yet provided ADL care due to being occupied with other tasks, and the night shift CNA did not report any issues or provide necessary care. The Director of Nursing (DON) and other staff members acknowledged the deficiency in care, with the DON stating that the expectation was for nursing staff to follow individualized care plans and check residents every two hours. Despite the resident's care plan for refusing care, there was no documentation of refusal, and staff did not re-approach the resident as required. The facility's policy emphasized the need for staff to re-approach residents who resist care, but this was not adhered to in the case of this resident.
Unlicensed Staff Administered Prescription Ointment
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services by allowing unlicensed nursing staff to administer a prescription ointment to a resident. The resident, a male with a history of dermatitis, pruritis, psoriasis, xerosis, and a bacterial skin infection, had a physician's order for Triamcinolone Acetonide 0.1% cream to be applied to specific areas of his body. However, a Licensed Practical Nurse (LPN) provided the cream to a Certified Nursing Assistant (CNA) to apply, which is against the facility's policy and state regulations that require medications to be administered by licensed personnel. The incident occurred when the resident complained of severe itching, and the CNA requested the cream from the LPN. The LPN gave the cream to the CNA, who then applied it to areas not specified in the physician's order. The Director of Nursing and the North Wing Unit Manager confirmed that only licensed nurses should handle medication administration. The facility's policy clearly states that only licensed individuals are permitted to administer medications, highlighting a breach in protocol and regulatory compliance.
Failure to Honor Full Code Status
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not honoring the resident's wishes for life-saving measures. The incident involved a resident who had a physician's order for Full Code status, meaning that in the event of cardiac or respiratory arrest, resuscitation efforts should be initiated. On the night of the incident, the resident was found not breathing by a CNA, who then informed an LPN. The LPN evaluated the resident and found no vital signs but did not check the resident's code status or initiate CPR. Instead, the LPN informed the Weekend Supervisor RN, who also failed to initiate CPR despite knowing the resident had a Full Code order. The resident, an elderly male with multiple health issues including dementia, cerebrovascular disease, and chronic kidney disease, was on hospice care but maintained a Full Code status as per his physician's order and care plan. The facility's staff, including the LPN and RN involved, did not follow the necessary protocols to verify the resident's code status and provide the required life-saving measures. The LPN relied on incorrect information from a report sheet and did not check the computer or other available resources to confirm the resident's code status. The RN, upon being informed of the situation, also did not take the necessary steps to initiate CPR or call for emergency assistance. Interviews with facility staff revealed a lack of awareness and adherence to the facility's policies regarding code status verification and the initiation of CPR. The staff involved did not follow the standard procedures for handling such situations, resulting in the resident not receiving the care he was entitled to under his Full Code status. The facility's failure to act according to the resident's advanced directives and physician's orders constituted neglect, as defined by their own policies.
Removal Plan
- The facility identified that resident #2 had a code status of Full Code; however, upon finding resident #2 with no respirations or pulse, the facility nurse failed to initiate Cardiopulmonary Resuscitation (CPR) in accordance with the physician's order and the resident/resident representative's advanced directives in place at the time of the incident.
- A root cause analysis was conducted using a combination of data collection methods, including interviews, surveys, and review of patient records. Conclusion: Root Cause was that the Resident's Code Status was not verified and CPR was not initiated by floor nurse or nurse supervisor.
- The facility initiated an investigation. Self-report called into Department of Children and Family Services/Adult protective services and an Immediate report sent into the State Agency by Abuse Coordinator. The LPN involved in the incident provided a statement and was suspended per facility policy pending investigation. The supervisor involved in the incident provided a statement and was suspended per facility policy pending investigation.
- The facility began re-education of all facility staff on Abuse/Neglect. 119 of 182 staff members have received education (documentation obtained). Education is at 65% and will remain ongoing until all staff members, including part-time and PRN (as needed) staff, are educated prior to the next scheduled shift.
- Emergency Quality Assurance Performance Improvement (QAPI) Meeting held to discuss problem identified and immediate actions needed, as noted above, with QAPI team present in person and Medical Director via telephone.
- The Medical Director reviewed emergency QAPI on paper and signed off.
- Licenses of LPN and RN Supervisor who did not initiate CPR reported to the Board of Nursing and were relieved of employment.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to honor a resident's advance directives and physician's order to provide basic life support (BLS) and initiate cardiopulmonary resuscitation (CPR) for a resident who was found unresponsive and not breathing. The resident, an elderly male with multiple health issues including dementia and cerebrovascular disease, was admitted to the facility with a Full Code status, indicating that resuscitation should be performed in the event of cardiac or respiratory arrest. Despite this, when the resident was found unresponsive, the staff did not verify his code status or initiate CPR. The incident occurred when a Certified Nursing Assistant (CNA) found the resident unresponsive and informed a Licensed Practical Nurse (LPN), who then evaluated the resident and found no vital signs. The LPN failed to verify the resident's code status and did not initiate CPR, instead calling a Registered Nurse (RN) Supervisor to the scene. The RN Supervisor also failed to initiate CPR, despite being aware of the resident's Full Code status, and pronounced the resident dead without attempting resuscitation. Interviews with staff revealed a lack of communication and understanding regarding the resident's code status, with the LPN relying on incorrect information and the RN Supervisor making assumptions about the resident's condition and code status. The facility's policies and procedures for handling such situations were not followed, leading to a failure to provide the necessary life-saving measures as per the resident's advance directives and physician's orders.
Removal Plan
- The facility nurse failed to initiate CPR in accordance with the physician's order and the resident/resident representative's advanced directives.
- A root cause analysis was conducted using a combination of data collection methods, including interviews, surveys, and review of patient records.
- The facility initiated an investigation. Self-report called to law enforcement and Adult Protective Services by Abuse Coordinator and per Adult Protective Services no report was generated. Immediate report sent to State Agency by Abuse Coordinator.
- The facility conducted audited 4 of 4 current residents who were under hospice care. Three of the 4 residents were DNR and 1 was Full Code. The Social Services Director spoke with the family of the resident who was a Full Code, and the family wished to continue with the same status.
- The Social Services Director completed an audit of all in-house residents to ensure physician's code status order, face sheet, care plans and documentation of resident's advanced directives matched all matched.
- An emergency Quality Assurance Performance Improvement (QAPI) meeting was held to discuss problems identified and immediate actions needed, with the QAPI team present in person and the Medical Director via telephone.
- The Medical Director reviewed the emergency QAPI meeting on paper and signed off.
- Licenses of nurses who did not initiate CPR were reported to the Board of Nursing.
- Mock Code Blue Drills performed for all licensed nursing staff for night shift and day shift. The PM shift will be completed; then going forward to be continued all 3 shifts each week times 4 weeks; all 3 shifts each month times 12 months.
- Re-education on Code Blue/CPR Policy/Protocol initiated. Education was at 45% completed with 49 of 109 licensed nurses completed and will remain ongoing until all staff members including part-time and PRN (as needed) staff are educated prior to the next scheduled shift.
Failure to Report and Perform CPR on Full Code Resident
Penalty
Summary
The facility failed to ensure that staff reported neglect related to not performing cardiopulmonary resuscitation (CPR) on a resident, which resulted in late reporting to the State Agency and Adult Protective Services. The incident involved a resident who was readmitted to the facility from the hospital with diagnoses including dementia, cerebrovascular disease, and adult failure to thrive, and was on hospice services. Despite being on hospice, the resident had a physician order for a Full Code, indicating that CPR should be performed in the event of cardiac arrest. On the night of the incident, a Licensed Practical Nurse (LPN) and a Registered Nurse (RN) failed to initiate CPR when the resident was found without vital signs, and they did not check the resident's code status as per the physician's order. The Weekend Supervisor RN, after confirming the resident's death, informed the Assistant Director of Nursing (ADON) and the resident's family but failed to report that CPR had not been performed. The RN later acknowledged that not following the physician's orders and the resident's wishes constituted neglect. The Director of Nursing (DON) and the Social Service Director, who was the facility's Abuse Coordinator, confirmed that the staff should have reported the neglect immediately according to facility policies. The facility's policies defined neglect as failing to provide needed care, and any suspicions of neglect were to be reported immediately to designated personnel.
Failure to Ensure Call Bells Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call bells were within reach for two residents, leading to a deficiency in accommodating their needs and preferences. Resident #1, who was admitted with a cerebral infarction and hemiplegia affecting her right side, was observed on multiple occasions with her call bell out of reach on the floor near the wall at the head of her bed. Despite being totally dependent on staff for various activities of daily living, the call bell was not accessible, as confirmed by both a Certified Nursing Assistant and the South wing Unit Manager. Similarly, Resident #2, who had a history of falling and other coordination issues, was also found with her call bell on the floor, out of reach. This resident required substantial assistance from staff for daily activities and had a care plan that specified the call bell should be within reach. Observations confirmed that the call bell was not accessible, and this was verified by the South wing Unit Manager and the Assistant Director of Nursing. Both residents' care plans included instructions to keep the call bell within reach, which were not followed, leading to the deficiency.
Deficiency in Providing Necessary ADL Services
Penalty
Summary
The facility failed to provide necessary services for a dependent resident to maintain activities of daily living, specifically regarding nail and oral care. The resident, who was admitted with diagnoses including cerebral infarction and hemiplegia, was noted to be dependent on staff for self-care due to severe cognitive impairment. Observations revealed that the resident's fingernails and toenails were overgrown and soiled, and there was a significant buildup of debris in her mouth. Despite the resident sometimes refusing care, there was no documentation of consistent nail or oral care being provided, nor were refusals adequately documented or communicated to the resident's family or physician. The facility's policy stated that residents unable to perform ADLs should receive necessary services to maintain hygiene, and staff should identify underlying causes of care resistance. However, the facility did not have care plans addressing the resident's refusal of oral and nail care. Interviews with staff confirmed the lack of documentation regarding the resident's care and refusals, and the Assistant Director of Nursing acknowledged the need for better documentation practices. The facility's failure to ensure proper nail and oral care for the resident represents a deficiency in maintaining the resident's personal hygiene and overall well-being.
Failure to Promote Dignity in Dining
Penalty
Summary
The facility failed to promote dignity in dining for a resident with Alzheimer's disease, dementia, and legal blindness. The resident was totally dependent on staff for activities of daily living, including eating. On multiple occasions, a CNA was observed feeding the resident while standing over her in the hallway, which is against the facility's policy that requires staff to be seated at the resident's eye level during feeding. The CNA acknowledged the improper practice but cited a lack of available seating as the reason for standing. Other CNAs also admitted to standing while feeding residents, citing comfort and better visibility as reasons, despite knowing it was against policy. Additionally, the facility staff, including the Unit Manager and Assistant Director of Nursing, referred to residents requiring eating assistance as 'Feeders,' which is against the facility's policy to avoid labels and promote dignity. The Unit Manager and Assistant Director of Nursing acknowledged the inappropriate terminology and the need to change the culture. The facility's policies on resident rights and assistance with meals emphasize treating residents with kindness, respect, and dignity, and specifically prohibit standing while feeding residents and using labels like 'Feeders.'
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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