The Bristol Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tampa, Florida.
- Location
- 1818 E Fletcher Ave, Tampa, Florida 33612
- CMS Provider Number
- 105140
- Inspections on file
- 29
- Latest survey
- January 5, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at The Bristol Care Center during CMS and state inspections, most recent first.
A resident with hemiplegia and hemiparesis following a cerebral infarction had a personal trust fund with balances well above the $2,000 SSI resource limit and received monthly Social Security deposits, while Medicaid records showed a $0 patient liability. The BOM stated the room and board charge was incorrect, but when surveyors requested proof that the resident or representative had been notified that the account was within $200 of the SSI asset limit, no documentation was available, and no policy or procedure for such notifications could be produced.
A resident with major depressive disorder and chronic pain repeatedly reported not receiving an expected $130 Personal Needs Allowance check from the state and stated she had been asking about it for an extended period without results. The grievance log showed a grievance involving dietary, social services, and the business office marked as resolved, but the underlying grievance document was unavailable. The Business Office Manager acknowledged the resident began complaining months after admission, noted that the resident had previously received the $130 at another facility, and indicated that limited contacts were made with DCF and a Medicaid specialist about the missing payment. However, there was no documentation of timely investigation, written grievance findings, or effective follow-up to resolve the resident’s complaint, contrary to the facility’s grievance policy and the business office job responsibilities.
A resident did not receive the prescribed Pregabalin 75 mg three times a day due to a failure in obtaining the necessary prescription from the physician. Despite attempts to contact the pharmacy, the medication was not available, and there was no documentation of physician notification. The facility's process for handling new admissions and controlled medications was not followed, leading to the deficiency.
A resident with flaccid hemiparesis was found on the floor after being left in the bathroom for privacy. CNAs moved the resident back to a wheelchair before a nurse could assess him, contrary to facility protocol. The nurse assessed the resident only after he was moved, and the DON confirmed that CNAs should not move residents post-fall until assessed by a nurse.
A resident with significant medical conditions was found on the floor by facility staff and moved by CNAs without a nurse's immediate assessment. The nurse was informed after the resident was already moved, contrary to facility protocol requiring a nurse's assessment before moving a resident post-fall.
A resident did not receive the prescribed Pregabalin 75 mg three times a day due to the facility's failure to ensure the medication was available and administered. The pharmacy did not have the prescription, and there was insufficient follow-up by staff to obtain it, resulting in a deficiency.
The facility failed to update PASRRs for several residents with mental disorders, leading to deficiencies in care planning. A resident with multiple mental health diagnoses did not have an updated PASRR, and another resident's PASRR was not updated upon admission. Other residents had incomplete PASRRs, and the Social Services Director relied on the system for notifications, which did not occur.
The facility failed to provide necessary care for a resident with an immune deficiency syndrome, including timely lab work follow-up and communication of results. Another resident's request to change from a mechanical soft diet to a regular diet was not addressed, and routine lab work for a resident with chronic conditions was not conducted as ordered. The facility lacked policies for coordinating care and documenting refusals, leading to these deficiencies.
A LTC facility failed to consistently apply orthotic devices for residents, leading to deficiencies in care. One resident's orthotic was left out of reach, with no staff assigned to apply it. Another resident with contractures did not consistently receive prescribed orthotics, and a third resident's orthotic application was inconsistently documented. Staff interviews revealed confusion and lack of clear processes for orthotic application, particularly on weekends.
The facility failed to maintain a medication error rate below five percent, resulting in a 13.79% error rate. An LPN administered an incorrect dosage of Calcium Carbonate to a resident, and another LPN failed to administer three medications to a different resident, despite signing them off as given. The facility's policy on medication administration was not followed, leading to these errors.
A resident with moderate cognitive impairment reported missing clothing to the laundry staff, but no grievance was filed, and the issue remained unresolved. The facility's grievance policy was not followed, as confirmed by interviews with the Social Services Director, laundry supervisor, and DON.
A facility failed to thoroughly investigate an alleged abuse incident where a nurse reportedly slapped a resident's hand during a medication pass. The investigation was limited to interviews with the involved parties and did not include other residents who received care from the accused nurse. Additionally, there was a delay in obtaining statements from the residents involved, contrary to the facility's policy requirements.
Two residents in an LTC facility did not receive showers according to their care plans and preferences. One resident, with hemiplegia, preferred showers but documentation was inconsistent, and staff interviews revealed discrepancies in recording practices. Another resident, dependent on staff for bathing, had inaccurate records of bathing after being transferred to an acute care facility. The facility's policy on ADLs was not followed, leading to a deficiency in maintaining residents' hygiene and preferences.
A facility failed to obtain consent from a resident's POA before using funds to purchase a chair for a bed-bound resident. The BOM and DOR did not contact the family, and the OT assumed the BOM would notify them. The purchase was part of a Medicaid spend down, but the lack of communication and consent led to a grievance. The facility's policy requires informing residents of charges to their funds, which was not followed.
A resident's assessment was not updated within the required three-month period, leading to a deficiency. The resident, with multiple diagnoses, had a Quarterly MDS that was completed late. The MDS Coordinator admitted the MDS was closed late and was unsure of the exact due date, indicating it might have been due earlier.
A facility failed to conduct a Level II PASRR for a resident with serious mental illness, despite diagnoses of Major Depressive Disorder and Bipolar Disorder. The resident's initial Level I PASRR did not indicate the need for further evaluation, but a subsequent report identified the need for a Level II review. The facility's psychiatric meeting documentation also indicated the need for a Level II review, which was not conducted. The Social Service Director noted that the facility had a process for updating PASRRs but did not resubmit the resident for a Level II review after adding an anxiety diagnosis.
The facility failed to properly store urinary drainage bags for two residents, leading to potential infection risks. A resident's drainage bag was observed hanging from a wheelchair with tubing on the floor, while another resident's bag was on the floor under an over-bed table. Staff confirmed the improper storage, and the facility's policy lacked specific storage instructions.
A facility failed to obtain a physician order before administering oxygen to a resident with COPD and other conditions. The resident had been using oxygen therapy at night without a physician's directive, as confirmed by the resident and the DON. The facility's policy mandates a physician order for oxygen administration, which was not followed.
Failure to Notify Resident of Trust Account Approaching SSI Resource Limit
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident or responsible party when the resident’s personal trust account balance came within $200 of the $2,000 Supplemental Security Income (SSI) resource limit. The resident, admitted in 08/2022, had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and required assistance with personal care. Review of the resident’s personal trust fund statements showed a balance of $7,871.13 on 07/01/2025, $5,469.30 on 11/04/2025, $6,264.65 on 12/04/2025, and $6,216.12 on 01/02/2025, with monthly deposits of $964.00 from 07/2025 through the survey date. The Business Office Manager (BOM) stated the resident was receiving a Social Security payment of $964.00 and acknowledged that the patient liability (room and board charge) was wrong. A Notice of Case Action from the Department of Children and Families dated 02/11/2025 documented that the resident had Medicaid eligibility with a $0.00 patient liability for 12/2024, 01/2025, 02/2025, and 03/2025 ongoing. Despite this, when surveyors requested evidence on 01/05/2026 that the resident or resident representative had been notified that the resident’s assets were within $200 of the $2,000 limit, no documentation was provided. When asked the same day for a policy and procedure for notifying residents when their assets are within $200 of the $2,000 asset limit, the BOM was unable to provide any such document. These findings show that the facility did not provide required notification or have documented procedures for this notification requirement.
Failure to Implement Grievance Process for Resident’s Missing PNA Funds
Penalty
Summary
The deficiency involves the facility’s failure to implement its grievance process and promptly resolve a resident’s ongoing complaint regarding non-receipt of a $130 Personal Needs Allowance (PNA) check from the Department of Children and Families (DCF). Resident #8, admitted with diagnoses including major depressive disorder and chronic pain, reported receiving a $30 SSI check and expecting an additional $130 state check that she had not received despite asking about it since 2024. During interview, she stated she had been requesting assistance with this issue with nothing happening. The facility’s grievance log for December 2024 showed a grievance from this resident involving dietary, social services, and the business office, marked as resolved the next day, and the Social Service Director stated the resident had requested to see the Business Office Manager (BOM) during that period. However, the actual grievance document was not available for review prior to survey exit. The BOM confirmed the resident was admitted in September 2024 and began complaining about the missing $130 check approximately three to four months after admission, requesting information on why she was not receiving it. The BOM stated there was likely a grievance and that social services would handle it, and reported sending a DCF fax cover sheet in early September 2025 noting the resident was not receiving the $130 state check and asking DCF to update from the time of admission. The BOM also stated the matter was turned over to the facility’s contracted Medicaid Specialist, and provided an email indicating the specialist had made an inquiry to DCF about the PNAS check in September 2025. No further information was available to show follow-up efforts or resolution of the PNAS issue with DCF prior to survey entrance. This inaction occurred despite facility policy requiring prompt efforts to resolve grievances, written investigation and reporting by the grievance officer within five working days, and maintenance of grievance records, as well as the BOM’s job description requiring maintenance of written records of resident complaints and follow-up with Medicaid in a timely manner.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to follow physician orders for medication administration for one resident, who was admitted with a medical diagnosis that included subcortical and flaccid conditions affecting the right dominant side. The resident was prescribed Pregabalin 75 mg to be administered three times a day, starting from the day of admission. However, the resident did not receive the medication during five administration opportunities, as documented in the medical records. The deficiency arose because the prescription for Pregabalin was not sent to the pharmacy, and the medication was not available in the emergency drug kit. Despite the nurses' attempts to contact the pharmacy, they did not have the prescription, and there was no documentation indicating that the physician was notified to provide the necessary prescription. The facility's emergency medication drug list showed that Pregabalin 25 mg was available, but the required 75 mg dosage was not administered. Interviews with the nursing staff and the Director of Nursing revealed that the facility's process for handling new admissions and controlled medications was not followed. The nurses were expected to notify the physician and document the need for a prescription, but this was not done. The Director of Nursing confirmed that the medication should have been administered as prescribed, and the nurses should have continued to contact the physician until the medication was delivered.
Plan Of Correction
Immediate actions taken for residents found to have been affected: Resident #1 was discharged from the facility on. Identification of other residents having the potential to be affected: Current residents in the facility were reviewed by to ensure their medications requiring hard scripts were available in the medication cart. No other residents were affected by the deficient practice. Actions taken/systems put into place to reduce risk of future occurrence: Staff Development Coordinator/designee will re-educate licensed nurses by to ensure physicians are notified when a hard script is needed for a new medication and will continue to follow up with physician and/or pharmacy until medication is received. How the corrective actions will be monitored to ensure the practice will not recur: DON/designee will review new admissions to ensure hard scripts were received or sent to pharmacy to ensure medication is delivered and available to the resident 3 times a week for 2 weeks then 2 times a week for 2 weeks then weekly. The administrator will oversee audit completion and report findings in the monthly Risk Management/QA Committee meeting for 3 months or until substantial compliance is achieved.
Failure to Follow Protocol for Resident Fall Assessment
Penalty
Summary
The facility failed to provide adequate and appropriate health care by not ensuring that a resident was assessed immediately by a nurse after being found on the floor. The incident involved a resident who was originally admitted with diagnoses including flaccid hemiparesis affecting the right dominant side. On the day of the incident, the resident was assisted to the bathroom by two CNAs and left there for privacy. Shortly after, the resident was found on the floor by a housekeeper, and the CNAs lifted the resident back into a wheelchair before a nurse could perform an assessment. Interviews with staff revealed that the protocol requires a nurse to assess a resident before they are moved after a fall. However, in this case, the CNAs moved the resident without waiting for the nurse's assessment. The nurse, who was administering medication in another room at the time, assessed the resident only after the CNAs had already moved him. The Director of Nursing confirmed that CNAs are not allowed to move a resident after a fall until a nurse has conducted an assessment, which was not followed in this instance.
Plan Of Correction
D-Right to Adequate and Appropriate Health Care Immediate actions taken for residents found to have been affected: Resident #1 was discharged from the facility on. Identification of other residents having the potential to be affected: Residents within the past 30 days were reviewed to ensure they were evaluated by a licensed nurse prior to being moved to the bed or chair. No other residents were affected by the deficient practice. Actions taken/systems put into place to reduce risk of future occurrence: Staff Development Coordinator/designee will re-educate licensed clinical staff by on ensuring residents with are evaluated by a licensed nurse prior to the resident being moved to the bed or chair. How the corrective actions will be monitored to ensure the practice will not recur: DON/designee will review residents with weekly for 4 weeks then monthly x3 months to ensure residents are being evaluated by the nurse prior to being moved to the bed or chair. The administrator will oversee audit completion and report findings in the monthly Risk management/QA committee.
Failure to Assess Resident After Fall
Penalty
Summary
The facility failed to ensure that a resident was assessed immediately by a nurse after being found on the floor by facility staff. The incident involved a resident with a history of significant medical conditions, including subcortical and flaccid paralysis affecting the right dominant side. On the day of the incident, the resident was placed on the toilet by two CNAs and left alone for privacy. Shortly after, the resident was found on the floor by a housekeeper, and the CNAs assisted the resident back into a wheelchair without waiting for a nurse to conduct an assessment. Interviews with staff revealed that the nurse, who was administering medication in another room, was informed of the incident after the CNAs had already moved the resident. The nurse assessed the resident only after the CNAs had placed the resident in a wheelchair. Facility protocol dictates that CNAs should notify a nurse immediately and wait for an assessment before moving a resident who has fallen. The Director of Nursing and other staff confirmed that the CNAs did not follow the required protocol, which includes notifying the nurse, conducting an assessment, and completing an incident report before moving the resident.
Plan Of Correction
F 684 D- Quality of Care Immediate actions taken for residents found to have been affected: Resident #1 was discharged from the facility on. Identification of other residents having the potential to be affected: Residents within the past 30 days were reviewed to ensure they were evaluated by a licensed nurse prior to being moved to the bed or chair. No other residents were affected by the deficient practice. Actions taken/systems put into place to reduce risk of future occurrence: Staff Development Coordinator/designee will re-educate licensed clinical staff by on ensuring residents with are evaluated by a licensed nurse prior to the resident being moved to the bed or chair. How the corrective actions will be monitored to ensure the practice will not recur: DON/designee will review residents with weekly for 4 weeks then monthly x3 months to ensure residents are being evaluated by the nurse prior to being moved to the bed or chair. The administrator will oversee audit completion and report findings in the monthly Risk management/QA committee.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide physician-ordered medication for a resident, resulting in a deficiency. The resident was admitted to the facility with a hospital discharge medication list that included Pregabalin 75 mg to be administered three times a day. However, the resident did not receive the medication during five administration opportunities from admission until discharge. The medication administration record indicated that the medication was not available, and the pharmacy did not have the prescription. Interviews with staff revealed that the medication was not in the medication cart, and the pharmacy was contacted but did not have the prescription. The staff did not remember if the physician was contacted to obtain the prescription. The facility's emergency medication drug list showed that Pregabalin 25 mg was available, but the required 75 mg dose was not administered. The Director of Nursing confirmed that Pregabalin is a controlled medication requiring a prescription and that the medication was not delivered because the pharmacy did not receive a prescription. The facility's policy on administering medications states that medications should be administered safely, timely, and as prescribed. The Director of Nursing indicated that if a controlled medication is not available, the physician should be notified, and there should be documentation of this notification. Despite these procedures, the resident did not receive the prescribed Pregabalin, and there was a lack of documentation and follow-up to ensure the medication was provided.
Plan Of Correction
F 755 D- Pharmacy Services/Procedures/Pharmacist/Records Immediate actions taken for residents found to have been affected: Resident #1 was discharged from the facility on Identification of other residents having the potential to be affected: Current residents in the facility were reviewed by to ensure their medications requiring hard scripts were available in the medication cart. No other residents were affected by the deficient practice. Actions taken/systems put into place to reduce risk of future occurrence: Staff Development Coordinator/designee will re-educate licensed nurses by to ensure physicians are notified when a hard script is needed for a new medication and will continue to follow up with physician and/or pharmacy until medication is received. How the corrective actions will be monitored to ensure the practice will not recur: DON/designee will review new admissions to ensure hard scripts were received or sent to pharmacy to ensure medication is delivered and available to the resident 3 times a week for 2 weeks then 2 times a week for 2 weeks then weekly. The administrator will oversee audit completion and report findings in the monthly Risk Management/QA Committee meeting for 3 months or until substantial compliance is achieved.
Failure to Update PASRRs for Residents with Mental Disorders
Penalty
Summary
The facility failed to complete or update the Pre-admission Screening and Resident Reviews (PASRRs) for several residents with mental disorders or intellectual disabilities. This deficiency was identified for five out of eight residents reviewed. The PASRR process is crucial for determining the appropriate level of care and services required for residents with mental health diagnoses. The failure to update these screenings can lead to inadequate care planning and service provision. Resident #228 was admitted with multiple mental health diagnoses, including generalized anxiety disorder, bipolar disorder, and depression. A new diagnosis of brief psychotic disorder was added, but the Level I PASRR was not updated, and a Level II PASRR was not submitted. The Social Services Director (SSD) acknowledged the oversight, citing a timing issue in reviewing and updating the PASRR. Other residents, such as Resident #145 and Resident #163, also had outdated or incomplete PASRR screenings. Resident #145's PASRR was not updated upon admission to the current facility, and Resident #163's PASRR did not mark qualifying diagnoses. Resident #25 and Resident #60 had similar issues, with their PASRRs not reflecting their current mental health diagnoses or the need for a Level II evaluation. The SSD admitted to relying on the system to notify her of the need for a Level II PASRR, which did not occur, leading to these deficiencies.
Deficiencies in Resident Care and Lab Work Follow-Up
Penalty
Summary
The facility failed to provide necessary care and services for a resident with an immune deficiency syndrome. The resident expressed concerns about not receiving timely blood work results to assess the effectiveness of their antiretroviral therapy medication. Despite having a care plan that included obtaining labs as ordered and reporting results to the physician, there was a lack of follow-up on abnormal lab results. The Director of Nursing (DON) admitted to not being aware of the resident's treatment for immune deficiency syndrome and did not ensure timely lab work follow-up. The resident also reported a negative experience with a health department appointment, which led to a lack of further appointments being scheduled. Another resident, who had been on a mechanical soft diet due to previous speech therapy recommendations, expressed a desire to switch to a regular diet. Despite being cognitively intact and having communicated this request to the staff, there was no follow-up on the diet change. The resident's speech therapy had been discontinued due to exhausted benefits, and there was no recent evaluation to reassess the dietary needs. The facility lacked a policy for coordinating care with therapy, which contributed to the oversight. Additionally, the facility failed to maintain routine lab work for a resident with multiple diagnoses, including chronic kidney disease and diabetes. The resident's lab work, ordered to be completed on a specific date, was not found in the electronic results tab, indicating it was not conducted. The DON later provided a lab log showing the bloodwork had been refused, but there was no documentation of this refusal in the resident's records. This lack of documentation and follow-up on lab work orders highlights a deficiency in the facility's care processes.
Inconsistent Application of Orthotic Devices in LTC Facility
Penalty
Summary
The facility failed to provide appropriate care for residents requiring orthotic devices, as evidenced by observations, record reviews, and interviews. Resident #123 was observed with a left-hand brace/splint lying out of reach, and the resident reported that no staff applied the orthotic device, relying instead on a family member. The resident's care plan did not include instructions for applying the orthotic, and staff interviews revealed confusion about who was responsible for its application. The Director of Rehabilitation noted that the resident had trialed a splint but did not require it anymore, yet the resident expressed a need for the device. Resident #14 was observed with contractures and was not wearing the prescribed orthotic devices. The resident's care plan included orders for bilateral palm guards and elbow splints, but documentation and staff interviews indicated inconsistent application of these devices. The Director of Rehabilitation reported that a palm guard was missing and had been discarded by a CNA due to soiling, despite being washable. The facility lacked a clear process for applying splints on weekends, leading to further inconsistencies in care. Resident #31 was observed with orthotic devices not being consistently applied as per the care plan. The resident's records indicated orders for wearing a right elbow orthotic and a right-hand splint, but observations and documentation showed these were not consistently applied or documented. Interviews with staff revealed that the rehab tech was responsible for applying the splints, but there was no scheduled time for application, and documentation was incomplete. The facility's policies on range of motion and specialized rehabilitative services were not adequately followed, contributing to the deficiencies observed.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 13.79% error rate during the observed period. Twenty-nine medication administration opportunities were observed, and four errors were identified involving two residents. For Resident #135, a Licensed Practical Nurse (LPN) administered a 750 mg Calcium Carbonate chewable tablet instead of the prescribed 600 mg tablet. This discrepancy was noted during a review of the resident's active medication orders. For Resident #220, another LPN prepared and administered several medications but failed to administer Metoprolol 50 mg, Omeprazole 20 mg, and Metformin HCL 1000 mg, despite signing them off as given. The LPN later admitted to not seeing these medications on the screen during the initial administration and claimed to have administered them later. However, the Medication Admin Audit Report indicated that all medications were signed off as given at the same time, raising concerns about the accuracy of the administration records. The facility's policy on medication administration emphasizes the importance of verifying the right medication, dosage, and time, which was not adhered to in these instances.
Failure to Address Resident's Grievance on Missing Clothing
Penalty
Summary
The facility failed to address a resident's grievance regarding missing clothing, which was reported by the resident during a facility tour. The resident, who had a moderate cognitive impairment with a BIMS score of 11, stated that she was missing a couple of pairs of pants and undershirts that her family had brought in. Despite informing the laundry staff about the missing items approximately three weeks prior, no grievance was filed on her behalf, and the issue remained unresolved. Interviews with facility staff revealed that the Social Services Director had not received any grievances from the resident or staff, and the grievance log showed no entries for this resident. The laundry supervisor and her assistant confirmed that the resident had reported the missing clothes, but a grievance was not initiated as per the facility's policy. The assistant laundry supervisor admitted to providing the resident with clothes from the donations pile instead of filing a grievance. The Director of Nursing stated that a grievance should have been initiated if the resident reported missing laundry. The facility's grievance policy requires prompt efforts to resolve grievances, which was not adhered to in this case.
Incomplete Investigation of Alleged Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged abuse incident involving a resident and a staff member. The incident was reported by a roommate who claimed that a nurse slapped the resident's hand during a medication pass. The resident involved, who had intact cognition and a history of mental health conditions, initially denied any mistreatment when interviewed. However, later statements indicated that the nurse may have lightly slapped the resident's hand after the resident pushed the nurse's hand away. The facility's investigation was incomplete as it only involved interviews with the directly involved parties and did not include other residents who received care from the accused staff member. Additionally, there was a delay in obtaining statements from the involved residents, which took seven days instead of the typical five-day window. The facility's policy required interviews with other residents and a review of all events leading up to the incident, which was not fully adhered to. The report highlights that the facility's abuse investigation guidelines were not thoroughly followed, as the investigation did not extend beyond the immediate parties involved. The facility's policy emphasizes the importance of protecting residents from abuse and ensuring a comprehensive investigation, which was not achieved in this case.
Failure to Provide Showers Per Care Plan and Resident Preference
Penalty
Summary
The facility failed to ensure that two dependent residents received showers according to their plan of care and personal preferences. Resident #123, who has diagnoses including hemiplegia and hemiparesis, expressed a preference for showers over bed baths, which was documented as very important in their care plan. However, the facility's documentation did not consistently indicate whether the resident received showers as preferred, with discrepancies noted in the timing and type of bathing provided. Interviews with staff revealed inconsistencies in documentation practices, with some staff unaware of the specific requirements for recording the type of bathing provided. Resident #283, who was dependent on staff for bathing and had a history of medical conditions such as hypotension and myocardial infarction, also did not receive showers as per their care plan. The facility's documentation showed that the resident was dependent on staff for bathing, but it did not specify the type of bathing received. Additionally, there were instances where the documentation inaccurately recorded bathing after the resident had been transferred to an acute care facility, indicating a lack of accurate record-keeping. The facility's policy on supporting activities of daily living (ADLs) emphasizes the importance of providing care to maintain or improve residents' abilities to perform ADLs. However, the facility did not adhere to this policy, as evidenced by the lack of proper documentation and failure to provide showers according to the residents' preferences and care plans. This deficiency highlights a gap in the facility's ability to ensure that residents receive the necessary care and services to maintain their hygiene and personal preferences.
Failure to Obtain Consent for Resident Fund Usage
Penalty
Summary
The facility failed to obtain consent from the designated Power of Attorney (POA) before utilizing funds from a resident's account to purchase a chair. The resident, who was incapacitated and bed-bound, had a chair purchased for her without the knowledge or consent of her responsible party or POA. The Business Office Manager (BOM) and Director of Rehabilitation (DOR) confirmed that they did not attempt to contact the resident's family or POA regarding the purchase. The Occupational Therapist (OT) conducted an assessment and determined the need for a chair, but did not notify the family, assuming the BOM would do so. The facility's policy requires residents to be informed in advance of any charges to their personal funds, which was not adhered to in this case. The resident's responsible party expressed dissatisfaction with the purchase, stating that the resident did not use the chair and was in hospice care. The BOM stated that the purchase was made as part of a Medicaid spend down, and the facility was acting as the resident's payee at the time. Despite the OT's assessment and trial of the chair, the lack of communication and consent from the POA led to the grievance. The Nursing Home Administrator acknowledged the POA's concerns and planned to address the issue, but the deficiency highlights a failure in the facility's process for managing resident funds and obtaining necessary consents.
Late Submission of Resident Assessment
Penalty
Summary
The facility failed to update a resident's assessment within the required three-month period, resulting in a deficiency. Resident #196, who was admitted with diagnoses including cerebral infarction, confusional arousals, white matter disease, cognitive communication deficit, and major depressive disorder, had a Quarterly Minimum Data Set (MDS) that was completed late. The MDS, which was supposed to be completed by a specific due date, was closed on 01/03/25 and not submitted until 01/07/25. During an interview, the MDS Coordinator, Staff A, acknowledged that the MDS was closed late and was unsure of the exact due date, suggesting it might have been due on 01/02/25. The delay in closing the MDS even by a minute past the due date was considered a late submission.
Failure to Conduct Level II PASRR for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to submit a resident for a Level II Pre-admission Screening and Resident Review (PASRR) despite the presence of serious mental illness diagnoses. The resident, who was observed lying in bed and covering her head with a blanket, had an admission comprehensive assessment indicating active psychiatric diagnoses, including depression and bipolar disorder. The initial Level I PASRR, completed by another facility, did not indicate a need for a Level II evaluation. However, a subsequent Level II PASRR Determination Summary Report identified the resident as having a Serious Mental Illness, with diagnoses such as Major Depressive Disorder and Bipolar Disorder, and recommended a Level II review if there was a significant change in mental status. Despite these findings, a later Level I PASRR screening did not require a Level II evaluation, and the facility's psychiatric meeting documentation indicated the need for a Level II review, which was not conducted. The Social Service Director stated that the facility had a process for updating PASRRs but did not resubmit the resident for a Level II review after adding an anxiety diagnosis, as the resident already had a previous Level II evaluation. The facility's policy requires all new admissions to be screened for mental disorders and referred for a Level II evaluation if necessary, but this process was not followed in this case.
Improper Storage of Urinary Drainage Bags
Penalty
Summary
The facility failed to ensure proper storage of urinary drainage bags and tubing for two residents with urinary catheters, leading to potential infection risks. Resident #91 was observed with a urinary drainage bag hanging from the wheelchair frame under the seat, with the catheter tubing dragging on the floor. This was confirmed by a registered nurse who assisted the resident into the shower room to adjust the tubing. The resident's treatment administration record indicated that staff were required to ensure the use of a securing device for the urinary catheter, perform catheter care with soap and water every shift, and change the urinary catheter bag and tubing as needed for blockage or signs of infection. Similarly, Resident #18 was observed with a urinary drainage bag on the floor under the over-bed table. A certified nursing assistant acknowledged that the bag should not be on the floor and repositioned it to hang from the bed frame. The resident's treatment administration record also required staff to ensure the use of a securing device for the urinary catheter every shift, perform catheter care with soap and water every shift, and change the urinary catheter bag and tubing as needed. The Director of Nursing/Infection Preventionist confirmed that urinary bags should not be on the floor, although the facility's urinary catheter care policy did not specify how the drainage bag should be stored.
Lack of Physician Order for Oxygen Administration
Penalty
Summary
The facility failed to ensure a physician order was available prior to providing oxygen administration for a resident. An observation revealed an oxygen concentrator with a nasal cannula at the bedside of a resident who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), ataxia, heart failure, and major depressive disorder. A review of the physician orders showed no current order for oxygen administration, despite the resident having been provided with oxygen therapy starting on a specific date as noted in the Nurses Note. Interviews with the resident and the Director of Nursing (DON) confirmed the absence of a physician order for the oxygen therapy. The resident stated that he had been using oxygen therapy at night for a couple of weeks and managed the oxygen concentrator himself. The DON acknowledged that a physician order is necessary to guide staff on the oxygen administration specifics, such as the number of liters, frequency, and form of delivery. The facility's policy on oxygen administration also requires verification of a physician's order before proceeding with the procedure.
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.
