Treasure Isle Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in North Bay Village, Florida.
- Location
- 1735 N Treasure Drive, North Bay Village, Florida 33141
- CMS Provider Number
- 105408
- Inspections on file
- 29
- Latest survey
- October 2, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Treasure Isle Care Center during CMS and state inspections, most recent first.
Staff left unattended, unlocked computer screens displaying resident information visible at multiple nursing stations, and a document with resident information was left on a treatment cart in a hallway. LPNs acknowledged that facility protocol requires information to be kept private, but admitted to leaving it exposed while away or assisting residents. These actions did not comply with the facility's privacy policy.
A CNA was witnessed by an LPN physically abusing a resident with severe cognitive impairment by slapping the resident on the buttocks during hygiene care. The resident, who was fully dependent on staff and unable to communicate, was not protected from abuse as required by facility policy. The CNA admitted to the action, which was prompted by frustration and stress.
Surveyors found that medication carts on two nursing units were left unattended and unsecured, with one cart unlocked and another with medications left on top. Both a supervisor RN and an LPN acknowledged that facility protocol requires medications to be locked and secured when not attended.
The facility failed to implement effective infection prevention and control practices, with observations of unsanitary conditions and improper handling of medical equipment and PPE. Residents' rooms were cluttered and unclean, with open and spoiled food items, soiled linens, and dirty bathrooms. Medical waste was improperly stored, and staff did not adhere to PPE protocols for residents under Enhanced Barrier Precautions. Interviews revealed confusion and non-compliance with infection control policies.
The facility failed to maintain a safe, clean, and clutter-free environment, with call lights out of reach for several residents, obstructed emergency exits, and pest issues in resident rooms. Staff inconsistencies in adhering to policies and inadequate provision of clean bedding were also noted.
The facility failed to administer oxygen at the correct flow rates for two residents, contrary to physician orders. One resident with COPD and acute respiratory failure received 4 LPM instead of the ordered 2 LPM PRN, while another with interstitial pulmonary diseases received 3 LPM instead of the ordered 2 LPM continuously. A nurse confirmed the incorrect settings, admitting to not checking them at shift start.
The facility failed to effectively address repeated deficiencies in infection prevention and control, as identified under F880 during a recertification survey. Despite having a QAPI Committee that meets monthly, the facility's actions were insufficient in addressing these issues, which have the potential to affect 168 residents. The committee, including various staff members, is responsible for ensuring quality care and identifying areas for improvement, but the repeated citation indicates a failure in their efforts.
A long-term care facility failed to ensure resident safety by allowing a resident to possess a knife and inadequately supervising an altercation between two residents. The knife was found in a resident's drawer, who admitted to bringing it from home despite knowing it was prohibited. In a separate incident, one resident struck another during a dining room altercation, leading to an arrest. The facility lacked clear policies on prohibited items and failed to intervene promptly during the altercation, contributing to the identified deficiencies.
The facility was cited for repeated deficiencies in resident rights and sufficient nursing staff. Staff were observed standing while feeding a resident, and two residents were seen wearing hospital-type gowns in the dining area. Despite monthly QAPI meetings, the facility failed to implement effective corrective actions.
The facility failed to provide adequate staffing, as residents were observed with unmet care needs, such as being in nightgowns at breakfast and waiting for personal care. CNAs reported high workloads, caring for 14 to 15 residents each, despite the facility's policy of limiting CNAs to 8 to 10 residents. The staffing coordinator and DON claimed staffing was based on census, but observations and interviews indicated insufficient staffing to meet resident needs.
The facility failed to label and date food stored in the pantry refrigerator, as required by policy. During an observation, two plastic bags with food items were found unlabeled and undated. The ADON confirmed these belonged to two residents and acknowledged the oversight. This deficiency could potentially affect 145 residents who eat orally.
The facility failed to follow infection control standards, as trash was left in hallways and a nurse entered a resident's room without donning appropriate PPE, despite contact precautions for the resident's history of candida auris. The facility's policy requires proper waste handling and PPE use to prevent infection spread.
A facility failed to ensure the proper use of a splint device for a resident with limited range of motion. The resident, who is non-verbal and has severe cognitive impairment, was often found without the splint on the correct hand, despite care plan instructions. Observations showed the resident with a rolled washcloth in the left hand instead of the prescribed splint for the right hand. The Rehabilitation Director confirmed the splint was on the wrong hand and corrected it, indicating a lapse in care plan adherence.
Three residents were not treated with dignity; one was fed by a standing CNA, and two were left in hospital gowns instead of personal clothing. A resident with severe cognitive impairment was slouched in bed while being fed, and another resident reported wearing a gown due to staff delays. Staff cited insufficient help as a reason for leaving residents in gowns.
A resident with multiple medical conditions did not receive a package containing frozen foods in a timely manner, leading to the food spoiling. The package was delivered over the weekend and left unopened, resulting in the food being defrosted and spoiled. Despite the resident filing a grievance, the issue was not resolved appropriately, highlighting a deficiency in the facility's handling of resident packages.
A resident with severe cognitive impairment and osteomyelitis was inaccurately coded on the MDS for splint device use, despite orders and care plans indicating daily application. The resident's care plan included interventions for range of motion and splint application, confirmed by the Rehabilitation Director, yet the MDS recorded zero days of splint use.
The facility failed to complete PASRR Level I and Level II screenings for residents with serious mental illness or intellectual disabilities. One resident with schizophrenia and depression did not have a complete PASRR Level I, and another resident with major depressive disorder and psychosis did not have a Level II PASRR requested. Staff interviews revealed issues with access to resources and oversight in reviewing PASRR forms.
A resident with severe cognitive impairment and multiple health issues was not properly cared for, as staff failed to implement the care plan for maintaining range of motion and skin integrity. The resident was observed without the correct splint device and was not repositioned every two hours as required. The Rehabilitation Director confirmed the splint was incorrectly applied and corrected it during an observation.
A resident with multiple pressure ulcers was not repositioned as required, remaining in a supine position for extended periods without proper offloading. Despite the facility's policy on prevention protocols, the resident was not repositioned due to a lack of available pillows, leading to a deficiency in care.
A resident with diabetes was found with long, curling toenails, indicating a failure in foot care. Despite a policy for podiatrist visits, the resident's name was not on the list, and a unit manager improperly trimmed the nails. The DON confirmed that only the podiatrist should perform this task for diabetic residents.
A facility failed to properly dispose of a medicated patch and maintain accurate records for controlled substances. A nurse disposed of a patch in a resident's trash instead of a sharps container, violating policy. Additionally, discrepancies were found in the narcotic count sheets for two residents, with an LPN admitting to not signing out medications immediately after administration.
A facility failed to properly store drugs and biologicals, as evidenced by an RN leaving IV medication unattended in a resident's room and expired items found in the medication storage room. The RN acknowledged the medication should not have been left out of sight, and the DON confirmed that all shifts are responsible for checking the medication room.
Failure to Protect Resident Health Information Privacy
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records on three out of five nursing units. Observations revealed that unattended, unlocked computer screens displaying resident information were left visible at the nursing stations on units three and five. Additionally, on unit four, a document containing resident information was left unattended on top of a treatment cart in the hallway. These incidents were documented with photographic evidence and confirmed by staff interviews. Staff members acknowledged that facility protocol requires computer screens to be turned off and resident information to be kept private when unattended. However, staff admitted to leaving information exposed due to being away from the computer or assisting residents. Review of the facility's Health Information Management: Privacy policy confirmed the requirement to protect individually identifiable health information in all forms, but the observed actions did not comply with this policy.
Failure to Protect Resident from Physical Abuse During Hygiene Care
Penalty
Summary
A staff member failed to protect a resident from abuse during hygiene care. Specifically, a Certified Nursing Assistant (CNA) was witnessed by a Licensed Practical Nurse (LPN) slapping a resident on the buttocks with an open hand. The incident occurred while the resident, who had severe cognitive impairment, was dependent on staff for all hygiene care and was unable to communicate effectively. The CNA admitted to slapping the resident due to frustration with the resident's crying and personal stress. The resident involved had a history of cerebral infarction, cognitive communication deficit, and Alzheimer's disease, and was care planned for total assistance with activities of daily living. The care plan included instructions for staff to converse with the resident and explain care tasks, but these interventions were not followed during the incident. The event was directly observed and documented by the LPN, and the CNA acknowledged the action when interviewed.
Unsecured Medication Carts Observed on Two Nursing Units
Penalty
Summary
Surveyors observed that medications and biologicals were not properly secured on two nursing units. On Unit 1, an unattended and unlocked medication cart was found, with photographic evidence supporting the observation. The supervisor RN confirmed that the cart should have been locked when not attended. On Unit 5, medications were left on top of an unattended medication cart, also documented with photographic evidence. The LPN present acknowledged that medications should be stored inside the cart but stated they became nervous. Review of the facility's policy indicated that medications are to be stored properly and accessible only to authorized personnel. At the time of the survey, there were 162 residents in the facility.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement effective infection prevention and control practices, as evidenced by multiple observations of unsanitary conditions and improper handling of medical equipment and personal protective equipment (PPE). Several residents' rooms were found to be cluttered and unclean, with open and spoiled food items, soiled linens on the floor, and dirty bathrooms. Additionally, there were instances of medical waste, such as soiled gauze pads and used syringes, being improperly stored in residents' rooms, contributing to an increased risk of infection. Specific observations included a room shared by three residents that contained open food items, empty containers swarmed with flies, and a dirty bathroom. Another room had a urinal with urine visible from the hallway, and soiled floors with trash. A resident with a tracheostomy and feeding tube had soiled gauze pads and an open packet of unused gauze pads on their bedside table, attracting flies. Another resident, who required Enhanced Barrier Precautions due to an indwelling catheter, had their drainage bag on the floor, and staff failed to wear the appropriate PPE while providing care. Interviews with staff revealed a lack of understanding and adherence to infection control protocols, particularly regarding the use of PPE for residents under Enhanced Barrier Precautions. The Infection Control Preventionist acknowledged staff confusion about PPE requirements, and the Environmental Services Director stated that floors are cleaned daily, yet observations indicated otherwise. The facility's policies on infection prevention and control, as well as Enhanced Barrier Precautions, were not effectively implemented, leading to the identified deficiencies.
Deficiencies in Environmental Safety and Cleanliness
Penalty
Summary
The facility failed to ensure a safe, clean, and clutter-free environment for its residents, as evidenced by multiple observations of call lights being out of reach for several residents, including Resident #4, Resident #6, Resident #7, Resident #8, Resident #11, and Resident #12. Despite the facility's policy requiring call lights to be within reach, staff interviews revealed inconsistencies in adherence to this policy. Some staff members acknowledged the importance of keeping call lights accessible, while others admitted to not always ensuring this, especially if residents expressed disinterest in using them. There was no documentation of instances where residents refused to have call lights within reach. The facility also failed to maintain a pest-free and safe environment in residents' rooms. Observations noted cluttered and soiled conditions, with open food items and rotted fruit attracting flies in several rooms, including rooms 106, 107, 108, and 109. Staff interviews confirmed the presence of flies and acknowledged the need for regular pest control services. Additionally, the facility's emergency exits were obstructed by furniture and linen bins, compromising safety. Staff interviews revealed challenges in maintaining clear exits due to the placement of soiled and clean linen bins. Further observations highlighted inadequate provision of clean and sufficient bedding for residents. Resident #4 was observed with a torn and shredded blanket, which was insufficient to keep her warm. Staff confirmed the lack of additional blankets available at the time. The facility's policy emphasizes maintaining a clean and comfortable environment, yet the observations and staff interviews indicate a failure to meet these standards, contributing to the deficiencies noted in the report.
Failure to Administer Correct Oxygen Flow Rates
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents by not administering oxygen at the correct flow rate as ordered by their physicians. Resident #4, who has a history of Chronic Obstructive Pulmonary Disease with Exacerbation and Acute Respiratory Failure with Hypoxia, was observed receiving oxygen at a flow rate of 4 Liters Per Minute (LPM) via nasal cannula, despite the physician's order specifying 2 LPM as needed for shortness of breath. This discrepancy was noted during observations at two different times on the same day. Similarly, Resident #5, diagnosed with Interstitial Pulmonary Diseases and Acute Respiratory Failure with Hypoxia, was observed receiving oxygen at a flow rate of 3 LPM, contrary to the physician's order of 2 LPM continuously. The incorrect flow rates for both residents were confirmed by Staff G, a Registered Nurse, who admitted to not checking the oxygen settings at the start of her shift. The facility's policy on oxygen therapy, which requires verification of physician orders and application of the correct liter flow, was not adhered to in these instances.
Repeated Deficiencies in Infection Control
Penalty
Summary
The facility failed to effectively implement plans of action to correctly identify and address quality deficiencies related to repeated deficient practices in infection prevention and control, specifically under F880. This deficiency was identified during a recertification survey, with the exit date noted as June 13, 2024. The facility's Quality Assessment and Assurance (QA & A) Compliance policy and procedure, effective since July 2022, outlines the purpose of the committees to review and analyze facility-related data, evaluate the effectiveness of improvement plans, and direct appropriate actions in response to identified issues. However, the facility's actions were insufficient in addressing the repeated deficiencies in infection control, which have the potential to affect 168 residents residing in the facility at the time of the survey. The facility's survey history revealed that despite having a Quality Assurance and Performance Improvement (QAPI) Committee that meets monthly, the repeated citation for F880 indicates a failure in the systematic review of data, identification of root causes, and implementation of corrective actions. The QAPI committee, which includes a wide range of facility staff such as the Administrator, Director of Nursing, and Infection Preventionist, is tasked with ensuring quality care and identifying areas for improvement. However, the continued citation suggests that the committee's efforts were not effective in addressing the infection control deficiencies, as evidenced by the repeated findings during the survey.
Safety and Supervision Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure the safety of its residents by allowing a resident to possess a knife, which was discovered during a survey. The knife was found in the drawer of a resident who shared a room with three other residents. The resident admitted to bringing the knife from her sister's house to peel mangoes, despite knowing that knives were not allowed in the facility. The facility's Director of Nursing (DON) and Nursing Home Administrator (NHA) were informed of the situation and acknowledged the seriousness of the issue. The facility did not have a policy explicitly prohibiting knives, and there were no signs indicating that knives were not allowed. In another incident, the facility failed to provide adequate supervision during an altercation between two residents, resulting in one resident being struck by another. The altercation occurred in the dining room when one resident refused to move from a table, leading to the other resident punching him in the face. The incident was reported to the DON and NHA, but it did not meet the criteria for further investigation. The resident who was struck sustained a skin tear to the upper lip but did not report any pain or distress. The resident who initiated the altercation was arrested by law enforcement due to aggressive behavior. The facility's incident report revealed multiple alleged abuse incidents and resident-to-resident altercations over a period of time. Despite the facility's policies and procedures aimed at reducing the risk of abuse and neglect, the incidents highlight a failure to effectively manage and prevent such occurrences. The facility's response to the incidents, including the lack of immediate intervention during the altercation and the absence of clear policies regarding prohibited items, contributed to the deficiencies identified during the survey.
Repeated Deficiencies in Resident Rights and Staffing
Penalty
Summary
The facility failed to adhere to its Quality Assurance Performance Improvement (QAPI) policy and did not effectively implement corrective actions to address repeated deficiencies. During a recertification survey, the facility was cited for F550-Resident Rights/Exercise of Rights due to staff failing to ensure dignity during dining, and F725 Sufficient Nursing Staff. In a subsequent survey, the facility was again cited for F550, as staff were observed standing while feeding a resident, and two residents were seen wearing hospital-type gowns in the dining area. The facility was also cited again for F725, indicating ongoing issues with sufficient nursing staff. Despite monthly QAPI meetings, the facility's actions were insufficient to address these deficiencies effectively.
Insufficient Staffing Levels in LTC Facility
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as observed during a survey conducted from June 11 to June 13, 2024. During this period, residents were seen in the activity area with urine odor and wearing nightgowns at breakfast time, indicating a lack of timely personal care. Additionally, some residents were still in bed waiting to be bathed and dressed by mid-morning. Interviews with Certified Nursing Assistants (CNAs) revealed that they were responsible for caring for 14 to 15 residents each, with most requiring total care, making it difficult for them to complete their tasks effectively. The staffing coordinator, who had been in the position for three weeks, reported that the schedule was based on the census and that a Registered Nurse was available 24 hours a day. However, the CNAs expressed dissatisfaction with their workload, despite the facility's policy stating that CNAs should not have more than 8 to 10 residents to care for. The Director of Nursing confirmed that the staffing schedule was prepared based on the census and that the facility had enough staff on every shift. Despite this, the observations and CNA interviews indicated that the staffing levels were insufficient to provide the necessary care for all residents.
Failure to Label and Date Resident Food in Refrigerator
Penalty
Summary
The facility failed to ensure that food stored in the pantry refrigerator in Section 1 was labeled with the resident's name and dated, as required by their policy. This deficiency was identified during an observation on June 12, 2024, at 9:27 AM, where two plastic bags containing food items were found unlabeled and undated. The first bag contained a package of string cheese, and the second bag contained sugar cane and a protein drink. The Assistant Director of Nursing confirmed that these bags belonged to two residents and acknowledged that they were not labeled or dated, which is against the facility's policy for safe handling, storage, and reheating of food brought in by visitors or from outside sources. The facility's policy, effective March 2022, mandates that food items intended for later consumption must be stored in a sealed container in the nourishment room or pantry refrigerator, labeled with the current date and the resident's name. This policy is communicated to visitors and residents through the resident handbook, and staff are instructed to ensure compliance. The failure to adhere to this policy has the potential to affect 145 out of 169 residents who consume food orally at the facility.
Infection Control Deficiency: Improper PPE Use and Trash Disposal
Penalty
Summary
The facility failed to adhere to infection control standards and transmission-based precautions, as evidenced by observations of trash left in hallways and staff not donning appropriate personal protective equipment (PPE) before entering a resident's room. On two separate occasions, bags of trash were observed on the floor in the nursing section, which is against the facility's policy for handling waste. Additionally, a registered nurse was observed entering a resident's room without wearing gloves, despite the room being marked for contact precautions due to the resident's history of candida auris. The resident involved had a diagnosis of candidiasis and was under contact precautions as per physician orders. The resident's care plan indicated a self-care performance deficit, requiring staff to follow specific precautions to prevent infection spread. The charge nurse confirmed that staff are required to perform hand hygiene and don appropriate PPE before entering rooms with contact precaution signs. The facility's infection prevention and control policy outlines the need for standard precautions and organism-specific precautions to prevent the spread of infections.
Improper Use of Splint Device for Resident with Limited ROM
Penalty
Summary
The facility failed to ensure the proper use of a splint device for a resident with limited range of motion. Observations revealed that the resident, who is non-verbal and has severe cognitive impairment, was frequently found without the splint device on the correct hand. The resident was observed multiple times with a rolled washcloth in the left hand instead of the prescribed splint, which was intended for the right hand. The care plan and medication administration records indicated that the splint should be applied to the right hand daily before breakfast and removed after lunch, but this was not consistently followed. The resident's medical history includes cerebral infarction, type 2 diabetes mellitus, dysphagia, muscle wasting, osteomyelitis of the vertebrae, and a communication deficit, making them dependent on staff for activities of daily living. Despite the care plan's instructions and the resident's vulnerability, staff failed to apply the splint correctly, as confirmed by the Rehabilitation Director during an observation. The director noted that the splint was on the wrong hand and corrected it, highlighting a lapse in adherence to the prescribed care plan for maintaining the resident's range of motion.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure that three residents were treated in a dignified manner. Resident #131 was observed being fed by a CNA who was standing, despite the presence of a chair in the room. This resident, who has severe cognitive impairment and is dependent on staff for all activities of daily living, was slouched in bed during the feeding. The CNA acknowledged the inappropriate feeding position and left the room. Staff B mentioned that the CNA was not a regular staff member on the floor and was only assisting with feeding. Residents #27 and #473 were observed wearing hospital gowns instead of their own clothing, which compromised their dignity. Resident #27, who has intact cognition and requires only partial assistance for dressing, reported wearing a gown because staff were late in dressing him. There was no documentation indicating that wearing a gown was his preference. Resident #473, who has severe cognitive impairment and requires assistance with dressing, was also observed in a gown. Staff indicated that due to insufficient help, residents were left in gowns if they were awake during the night shift. The administrator and Assistant NHA were informed of these concerns.
Failure to Deliver Package Timely Resulting in Spoiled Food
Penalty
Summary
The facility failed to ensure timely delivery of a package containing frozen foods to a resident, resulting in the food being defrosted and spoiled. The resident, who has multiple medical conditions including gout, end-stage renal disease, and diabetes mellitus, was cognitively intact and able to make his own decisions. The package was delivered over the weekend and left unopened, leading to the food spoiling before it was given to the resident. The resident filed a grievance about the incident, but it was marked as resolved on the same day without any corrective action being taken. Interviews with facility staff revealed that the package was delivered to the back of the building and left there over the weekend. The Director of Nursing and the Administrator confirmed that the food was spoiled by the time it was discovered. The Social Services Director and Activities Assistant indicated that the facility did not have adequate storage for the large box of frozen food, and the family was informed about the situation. Despite the grievance filed by the resident, the issue was not addressed appropriately, leading to the deficiency noted in the survey.
Inaccurate MDS Coding for Splint Device Use
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident, identified as Resident #131, who was not accurately coded for the use of a splint device. Resident #131, a vulnerable individual with severe cognitive impairment and dependent on staff for activities of daily living, was admitted with clinical diagnoses including osteomyelitis of the vertebrae and a communication deficit. The resident had active orders for right hand range of motion and mobility, including the application of a right hand splint daily as tolerated. However, the Quarterly MDS assessment inaccurately recorded the use of the splint device as zero days, despite the care plan and orders indicating its daily application. The care plan for Resident #131, initiated and revised over several months, included interventions for maintaining range of motion and the application of the right hand splint. The Rehabilitation Director confirmed that the resident was on occupational therapy, which included the use of splints on the right hand. Despite these documented interventions and orders, the MDS assessment failed to reflect the actual use of the splint device, leading to the identified deficiency in accurately coding the resident's care needs.
Deficiency in PASRR Completion for Residents
Penalty
Summary
The facility failed to ensure the completion of the Preadmission Screening and Resident Review (PASRR) Level I and Level II for certain residents, which is a requirement for identifying serious mental illness or intellectual disabilities. Specifically, the PASRR Level I was not completed for two residents, and a Level II PASRR was not requested for another resident. This deficiency was identified during a survey and had the potential to affect 168 residents residing in the facility at the time. One resident was observed to be in bed, either sleeping or awake, with a call light always within reach, but showed signs of distress or anxiety and did not respond to questions. The resident had a history of schizophrenia and depression, and was receiving antipsychotic and antidepressant medications. Despite these diagnoses, the PASRR Level I did not identify any serious mental illness, and sections of the form were incomplete. Another resident, who was also in bed with a call light in reach, had diagnoses including major depressive disorder and unspecified psychosis. The PASRR Level I indicated a need for further review due to recent psychiatric treatment, but a Level II PASRR was not requested. Interviews with facility staff revealed that the PASRR process was not properly followed due to issues such as lack of access to the state agency website and oversight in reviewing the PASRR forms. The Social Services Director admitted to not having access to the necessary resources to update the PASRR forms at the time of admission, leading to incomplete documentation. The facility's policy requires that PASRR screenings be completed prior to admission to ensure appropriate placement and identification of specialized services needed by residents.
Failure to Implement Care Plan for Resident's Range of Motion and Skin Integrity
Penalty
Summary
The facility staff failed to implement the care plan for a resident, leading to a deficiency in maintaining the resident's range of motion and skin integrity. The resident, who is non-verbal and has severe cognitive impairment, was observed multiple times without the appropriate splint device on the correct hand and was not repositioned every two hours as required. The care plan indicated that the resident should have a splint on the right hand, but observations showed the splint was often on the left hand or not applied at all, and the resident was consistently found lying on the same side for extended periods. The resident's clinical records revealed a history of cerebral infarction, type 2 diabetes mellitus, dysphagia, muscle wasting, osteomyelitis of the vertebrae, and communication deficits, making them highly vulnerable. Despite the care plan's instructions and active orders for right-hand splinting and regular repositioning, these were not consistently followed. The Rehabilitation Director confirmed the splint was incorrectly applied to the left hand and corrected it during an observation, highlighting the oversight in care delivery.
Failure to Reposition Resident Leads to Pressure Ulcer Care Deficiency
Penalty
Summary
The facility failed to provide necessary interventions to promote the healing of pressure ulcers for a resident, identified as Resident #146, who was observed in a supine position for extended periods without appropriate repositioning. Observations on multiple occasions revealed that the resident remained in a supine position on an air mattress for more than two hours, which is contrary to the care plan that required regular repositioning to prevent further skin breakdown. The resident had a history of multiple pressure ulcers, including two Stage 2, three Stage 3, and one Stage 4 pressure ulcer upon admission, necessitating diligent care to prevent worsening of these conditions. The deficiency was further highlighted when the wound care nurse and a CNA failed to reposition the resident appropriately after wound care, leaving the resident in a supine position without a pillow to offload pressure from the buttocks. The CNA admitted to not repositioning the resident due to a lack of available pillows, indicating a failure to adhere to the facility's prevention protocols. The facility's policy emphasized the importance of using tools like glide sheets and pillows to prevent skin breakdown, but these were not utilized effectively in this case, leading to the deficiency in care for Resident #146.
Failure to Provide Appropriate Foot Care for Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, identified as Resident #35, who was observed with long and curling toenails on multiple occasions. Despite having a diagnosis of type two diabetes, which requires careful foot care, the resident reported that his toenails had never been trimmed since his admission. The facility's protocol indicated that a podiatrist visits weekly to cut toenails, especially for diabetic residents, but Resident #35's name was not on the list for the podiatrist's visit in June 2024. The unit manager confirmed the need for toenail trimming upon observation and proceeded to cut the resident's nails, which was against the facility's policy for diabetic residents. The Director of Nursing later clarified that staff are not permitted to cut toenails for diabetic residents, as this is the responsibility of the podiatrist. The facility's policy for foot care was requested but not provided, indicating a lack of adherence to established procedures and communication breakdown regarding the resident's care needs.
Medication Disposal and Record-Keeping Deficiencies
Penalty
Summary
The facility failed to properly dispose of medication and maintain accurate records for controlled substances, leading to deficiencies in pharmaceutical services. During a medication administration observation, a registered nurse disposed of a medicated patch in a resident's trash can instead of a sharps container, which was against the facility's policy. The resident involved had a physician's order for a Scopolamine Patch to be applied every 72 hours. The facility's policy required non-controlled medications to be destroyed in the presence of a pharmacist or nurse and transferred to a pharmaceutical waste contractor, not disposed of in regular trash. Additionally, the facility failed to accurately reconcile controlled narcotics for two residents. A medication storage check revealed discrepancies between the recorded amounts on the Controlled Drug Declining Inventory sheets and the actual number of pills in the bingo cards for two residents. One resident's Lacosamide tablets were one short of the recorded amount, and another resident's Oxycodone tablets were also one short. The LPN responsible for administering these medications admitted to administering them but failing to sign them out on the narcotic sign-out sheet immediately, as required by the facility's policy for controlled substances.
Improper Storage of Drugs and Biologicals
Penalty
Summary
The facility failed to properly store drugs and biologicals, as evidenced by an incident involving a registered nurse (RN) who left intravenous (IV) medication unattended in a resident's room. During a medication administration observation, the RN placed the IV medication on a side table next to the resident and left the room to perform hand hygiene, leaving the medication out of direct vision. Upon returning, the RN acknowledged that the medication should not have been left out of sight. Additionally, the RN left three normal saline-filled syringes on the resident's side table after completing the medication administration, which was against protocol. Furthermore, an inspection of the facility's medication storage room revealed several expired items, including specimen collection swab and transport kits, COVID-19 test kits, saline bottles, hypodermic needles, and an IV start kit. These items were found despite the facility's medication storage policy, which mandates proper storage of medications and biologicals following manufacturers' or provider pharmacy recommendations. The Director of Nursing (DON) and a registered nurse acknowledged these concerns, noting that all shifts are responsible for checking the medication room, and the pharmacy conducts monthly checks.
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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