Trinity Regional Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Trinity, Florida.
- Location
- 2144 Welbilt Blvd, Trinity, Florida 34655
- CMS Provider Number
- 106079
- Inspections on file
- 19
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 3 (2 serious)
Citation history
Health deficiencies cited at Trinity Regional Rehab Center during CMS and state inspections, most recent first.
A resident with dementia, moderate cognitive impairment (BIMS 10), and a documented history of wandering, agitation, and exit-seeking was care planned as an elopement risk but did not have an electronic monitoring device in place when staff supervision lapsed during a CNA’s break. The resident opened a delayed egress door to a stairwell, then exited through an unalarmed first-floor door and an alarmed exterior door near the business office, with multiple staff later reporting they did not hear any alarms. The resident walked through the parking lot and onto nearby roads and was ultimately found about half a mile away by a CNA searching in her car. Interviews and records showed prior elopement risk evaluations, resolved use of an audible monitoring system, inconsistent staff knowledge of which residents were elopement risks, and lack of communication with the attending physician about removal of the monitoring device, leading surveyors to cite neglect related to failure to prevent elopement and respond to exit door alarms.
A cognitively impaired resident with dementia, moderate BIMS score, and documented exit‑seeking and wandering behaviors eloped from the facility after leaving a second‑floor hallway, entering a stairwell, and exiting through an unalarmed first‑floor door. The resident, who had previously been identified as an elopement risk and had worn an electronic monitoring device that was later discontinued, walked through the parking lot and onto public roads, traveling roughly half a mile away before being found off‑site by a CNA. Staff interviews and records showed inconsistent awareness of which residents were elopement risks, limited coverage of the electronic monitoring system to only the main lobby door, and no staff hearing any door alarms at the time of the incident, leading to a cited deficiency for failure to provide adequate supervision and prevent accidents.
Three residents with wounds requiring dressing changes were found to have dressings that were not labeled with the required date, time, or staff initials, contrary to facility policy and professional standards. Staff interviews confirmed that labeling is expected after care, but observations showed this was not consistently done.
A resident with multiple complex medical conditions was discharged while her appeal was still pending, and before all necessary home equipment and support services were in place. The facility proceeded with the discharge after determining the appeal was filed outside the 10-day window, despite having received notice of the scheduled hearing. The resident was left without essential equipment and adequate caregiver arrangements, resulting in dependence on a family member for personal care.
The facility failed to ensure kitchen staff adhered to food safety standards, as observed during a survey. Staff members were seen without required hairnets and beard guards, and a dietary aide handled food without gloves. The CDM admitted to forgetting safety gear, and a staff member was unaware of beard guard locations. Despite previous education, a dietary aide neglected glove use due to being busy, violating the facility's policy prohibiting bare hand contact with food.
The facility failed to properly store and label medications, with instances of unsecured medication cups, loose pills, and non-medical items in medication carts. A resident's room had unsecured ointments without self-administration orders, and the medication storage room had an unlocked narcotic refrigerator. The facility's policy on safe and secure medication storage was not followed.
The facility did not promptly resolve grievances related to call light delays, as noted in Resident Council meetings over four months. Despite repeated concerns about CNA availability during mealtimes and delayed call light responses, these issues were not documented in grievance logs. Interviews revealed inconsistencies in the grievance process, with staff failing to track and resolve recurring issues effectively.
The facility failed to provide timely wound care for four residents, with dressings not changed as per orders and some undated. A resident reported her dressing was unchanged for days, while another had soiled dressings not replaced. A third resident's bandage was not changed despite bleeding, and a fourth had an undated dressing with no treatment orders. The DON confirmed dressings should be dated and orders followed.
A resident with moderate cognitive impairment was observed with cigarettes and a lighter, despite needing supervision while smoking. The facility's policy required that smoking supplies be stored by the facility for residents needing supervision, but this was not followed. Staff confirmed the resident's need for supervision, yet she retained access to her smoking materials, indicating a failure in adhering to safety protocols.
A resident's PICC line dressing was not changed as ordered, leading to a deficiency in care. The dressing, dated 10/27, was not changed weekly as required, despite the resident receiving IV antibiotics for osteomyelitis. Observations noted remnants of a sticker and a new date written by staff without evidence of a proper dressing change, contrary to facility policy.
The facility failed to accommodate food preferences for two residents, leading to deficiencies in meal service. One resident with specific dietary restrictions due to medical conditions received meals that did not align with their needs, resulting in weight loss. Another resident repeatedly requested meals without gravy but continued to receive food with gravy. The Certified Dietary Manager acknowledged the issue, noting that resident choices are documented daily, but the dietary staff failed to follow the tray tickets.
The facility failed to adhere to infection control practices, including leaving respiratory equipment uncovered, improper handling of glucometers, and not implementing contact precautions for a resident suspected of having C-diff. Observations revealed uncovered ice scoops and shared IV equipment without proper precautions, contrary to facility policies.
Failure to Prevent Elopement of High-Risk Resident and Respond to Exit Door Alarms
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not responding to an exit door alarm and not providing adequate supervision to prevent an elopement. On the day of the incident, a CNA left the resident at the nurse’s station around 1:45 p.m. to go on lunch break. The resident, who had a history of exit-seeking and wandering behaviors, was later discovered missing from his room at approximately 2:15 p.m. A facility-wide missing resident code was initiated, and staff began searching the building and surrounding area. Multiple staff members reported they did not hear any door alarms at the time of the elopement. The resident had been admitted with diagnoses including unspecified sequelae of cerebral infarction, alcohol abuse with alcohol-induced anxiety disorder, unspecified dementia with moderate cognitive impairment, cognitive communication deficit, and syncope and collapse. His most recent MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and he was able to ambulate 150 feet with supervision or touching assistance. The care plan identified him as at risk for elopement due to exit-seeking behavior and ambulating without assistance in hallways, with interventions such as diversional activities, frequent visual checks, and use of an audible monitoring system. Elopement risk evaluations on multiple dates had identified him as an elopement risk, and prior progress notes documented escalating behavioral concerns, repeated attempts to leave through exit doors, agitation, combativeness, and exit-seeking behaviors. Despite this history, the resident did not have an electronic monitoring device in place at the time of the incident, and the prior intervention to use an audible monitoring system had been resolved. The resident exited from a second-floor hallway door near the maintenance office into a stairwell, holding the door handle for approximately 30 seconds to open the delayed egress door, then proceeded down the stairs to a first-floor exit door that had no alarm and could be opened freely from the inside. He then exited through another alarmed door near the business office to the parking lot, but staff reported not hearing any alarms. The resident walked through the parking lot and onto nearby roads, ultimately being found approximately 0.6 miles from the facility by a CNA who left in her car to search for him. Interviews revealed inconsistent staff understanding of which residents were at elopement risk and who should be wearing electronic monitoring devices, with at least one CNA stating she was unsure how to identify elopement-risk residents or whether any such residents were currently in the facility. The facility’s failure to supervise the resident adequately and to ensure effective functioning and response to exit door alarms resulted in an elopement that surveyors determined created a likelihood for serious injury and/or death and was cited at Immediate Jeopardy. Additional interviews highlighted gaps in communication and assessment related to the resident’s elopement risk. The Nursing Home Administrator stated that the resident did not exhibit wandering and exiting behaviors prior to the incident, despite documentation of prior exit-seeking and agitation. The resident’s primary care physician described him as having cognitive decline with variable mentation and stated that if the facility decided to remove the electronic monitoring device, this should have been communicated to him; he also reported he had not been informed of any exit-seeking behaviors. Some staff, including an LPN and CNAs, acknowledged that the resident had shown exit-seeking behaviors in November and December, and one CNA stated that if staff had known more, they might have been more aware of the need to continue monitoring for elopement risk. The combination of the resident’s known elopement risk, removal of monitoring interventions, lack of staff awareness, and failure to respond to or detect door alarms led directly to the resident’s unsupervised departure from the facility.
Removal Plan
- Implemented 1:1 enhanced monitoring for Resident #1 upon return to the facility until discharge
- Updated Resident #1’s care plan
- Completed a PTSD evaluation for Resident #1 with no concerns identified
- Reviewed Resident #1’s elopement risk status; completed an updated elopement evaluation and updated the plan of care as indicated
- Interviewed Resident #1 upon return to the facility; resident described the path taken and what occurred to the NHA/DON
- Evaluated the identified exit door used to leave the unit for proper function and alarm; no issues identified
- Evaluated all facility internal exit doors for proper function; no issues identified
- Completed education on doors and alarms for 100% of staff
- Placed temporary auditory sensor alarms at identified secondary doors that exit the facility
- Held an Ad Hoc QAPI committee meeting to review the concern, approve corrective interventions, and approve a PIP
- Initiated mock elopement drills (every shift for one week, then daily for one week, then every other day ongoing per QAPI recommendations)
- Initiated education on the Missing Resident/Elopement policy/procedure (including elopement books) and Abuse/Neglect/Exploitation; educated all facility staff and contract therapy staff
- Reviewed records of previous daily exit door checks for the past 90 days to validate completion; continued daily door checks per QAPI direction
- Reviewed elopement books to ensure proper information is in place and books are easily accessible
- Verified functioning of the electronic monitoring device check machine
- Evaluated current residents for elopement risk; completed new elopement evaluations and reviewed/updated care plans as indicated
- Reviewed current residents with electronic monitoring devices to verify evaluation accuracy/appropriateness, proper orders, and documentation for placement; updated evaluation/order/care plan as indicated
- Checked the electronic monitoring device system at the front door and confirmed it was functioning
- Held a follow-up Ad Hoc committee meeting to review actions/interventions/outcomes and approve PIP items; Medical Director participated
- Educated direct care licensed nursing staff on completion of elopement evaluations
- Verified proper functioning of exit doors and alarms by the regional maintenance consultant
- Converted locked exit doors to remove delayed egress; exit doors now require key fob/keypad for exiting; educated all facility staff and contract therapy staff
- Educated direct care licensed nursing staff on interventions and notification for residents who refuse/remove wander guard device
- Verified resident photos and resident room name door tags for identification/verification and updated as indicated
- Held an Ad Hoc committee meeting to review steps taken and approve PIP item completion
- Held an Ad Hoc committee meeting; reviewed and updated the elopement drill tracking form/process and updated the location form to ensure all facility areas are assigned
- Initiated ongoing competency testing on resident elopement awareness and prevention (signs/symptoms of exit-seeking behavior, interventions, and notification); completed for facility staff and contract therapy staff
- Provided education to licensed staff regarding identifying elopement risk and locating electronic monitoring device status
Elopement of Cognitively Impaired Resident Due to Inadequate Supervision and Door Controls
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for a cognitively impaired resident who had been repeatedly identified as an elopement risk. The resident was admitted with diagnoses including unspecified dementia of unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, as well as cognitive communication deficit and a history of cerebral infarction, alcohol abuse with alcohol-induced anxiety disorder, and syncope and collapse. A quarterly MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and documented that the resident could ambulate 150 feet with supervision or touching assistance. The resident’s care plan included a focus area for risk of elopement, citing exit‑seeking behavior and ambulating without assistance in hallways, with interventions such as diversional activities, frequent visual checks, and use of an audible monitoring system via an electronic monitoring device, which had been initiated and then resolved prior to the incident. Elopement risk evaluations on multiple dates identified the resident as an elopement risk, and a prior physician order for a wander management bracelet had been in place but was discontinued before the elopement. In the months leading up to the incident, facility records documented ongoing concerns about the resident’s wandering and exit‑seeking behaviors. A palliative care note recorded that the resident’s representative was concerned about the resident’s wandering and overall safety. Nursing and psychology notes described escalating behavioral concerns, agitation, combativeness secondary to confusion, not following safety instructions, and repeated attempts to leave the unit through an exit door. Staff documented periods of agitation and exit‑seeking in November and December, with multiple redirection attempts required to return the resident to his room. Despite these documented behaviors and repeated elopement risk evaluations, the resident did not have an electronic monitoring device in place at the time of the elopement, and the resident’s primary care physician stated he had not been informed of exit‑seeking behaviors or of the decision to remove the electronic monitoring device. On the day of the elopement, staff last observed the resident around the nurses’ station and his room shortly before the incident. A CNA reported leaving the resident at the nurses’ station before going on break and, upon returning, was unable to locate him in his room or the building. A missing resident code was initiated, and staff began searching. The resident had exited from the second‑floor hallway near the maintenance office into a stairwell by holding the door handle for approximately 30 seconds, then proceeded down the stairs to a first‑floor door that opened to the outside without an alarm. From there, the resident walked through the parking lot and onto nearby roads, ultimately traveling approximately 0.6 miles away from the facility toward streets with posted speed limits of 30 mph and 55 mph. Multiple staff members reported not hearing any door alarms, and interviews revealed inconsistent staff understanding of how to identify elopement‑risk residents and who should be wearing electronic monitoring devices. The resident was missing for about 10 minutes without staff knowledge before being located off‑site by a CNA and returned to the facility, where he stated he had been going for a walk and that no one saw him leave. This failure to supervise and to ensure effective elopement prevention measures resulted in a determination of Immediate Jeopardy. Additional interviews and record reviews highlighted gaps in staff awareness and communication related to elopement risk and monitoring systems. One CNA stated she was unsure how to identify residents at risk for elopement or who should be wearing an electronic monitoring device and did not know if any residents in the facility were at risk. The maintenance and housekeeping director stated that only the main lobby door was protected by the electronic monitoring device system and that other doors did not use these devices, while the regional nurse confirmed that the electronic monitoring device system only worked on the front door and would not have alerted at other exits. The nursing home administrator acknowledged that the resident had an elopement assessment upon admission and had previously worn an electronic monitoring device, but did not have one at the time of the incident, and that the door used to exit to the outside did not have an alarm. Staff accounts of the incident varied regarding the duration the resident was missing, but consistently indicated that no door alarms were heard and that the resident was found off facility grounds, damp from the rain, after the missing resident code was called. These documented actions and inactions formed the basis for the cited deficiency under the requirement to keep the environment free from accident hazards and to provide adequate supervision to prevent accidents.
Removal Plan
- Implemented 1:1 enhanced monitoring for Resident #1 upon return to the facility until discharge.
- Updated Resident #1's care plan.
- Completed a PTSD evaluation for Resident #1 with no concerns.
- Reviewed Resident #1's elopement risk and completed an updated elopement evaluation with plan of care updates as indicated.
- Interviewed Resident #1 upon return to the facility and evaluated the identified exit door used for proper function/alarm with no issues identified.
- Evaluated all facility internal exit doors for proper function with no issues identified.
- Completed education on doors and alarms for 100% of staff.
- Placed temporary auditory sensor alarms at identified secondary doors that exit the facility.
- Held an Ad Hoc QAPI committee meeting to review the concern, approve corrective interventions, and approve a PIP.
- Initiated mock elopement drills.
- Initiated education on the Missing Resident/Elopement Policy/Procedure (including elopement books) and Abuse/Neglect/Exploitation and completed education for all facility staff and contract therapy staff.
- Reviewed the prior 90 days of daily exit door checks to validate completion and continued daily door checks per QAPI direction.
- Reviewed elopement books to ensure proper information is in place and books are easily accessible.
- Verified functioning of the electronic monitoring device check machine.
- Evaluated current residents for elopement risk and completed new elopement evaluations with plan of care reviews/updates as indicated.
- Reviewed current residents with electronic monitoring devices to verify evaluation accuracy/appropriateness and proper orders/documentation and updated evaluation, order, and plan of care as indicated.
- Checked the electronic monitoring device system at the front door and confirmed it was functioning.
- Held a follow-up Ad Hoc committee meeting to review actions/interventions/outcomes and approve PIP items; Medical Director participated.
- Educated direct care licensed nursing staff on completion of elopement evaluations.
- Verified proper functioning of exit doors and alarms by the regional maintenance consultant.
- Converted locked exit doors to remove delayed egress, implemented keypad/key fob exit function, and educated staff and contract therapy staff.
- Educated direct care licensed nursing staff on interventions and notification for residents who refuse/remove wander guard device.
- Verified resident photos and resident room name door tags for identification/verification and updated as indicated.
- Held an Ad Hoc committee meeting to review steps taken and approve PIP item completion.
- Held an Ad Hoc committee meeting.
- Reviewed and updated the elopement drill tracking form/process to improve organization of the search and updated the location form to ensure all facility areas are assigned.
- Initiated ongoing competency testing related to resident elopement awareness and prevention (signs/symptoms of exit-seeking behavior, interventions, and notification) and completed testing for staff and contract therapy staff.
- Provided education to licensed staff on identifying elopement risk and locating electronic monitoring device status.
Failure to Label Dressings per Facility Policy
Penalty
Summary
The facility failed to follow its own resident care policies regarding the labeling of dressings, as required by their written procedures and professional standards of practice. Observations revealed that three residents had dressings or bandages that were not dated, timed, or initialed as specified in the facility's policy. Specifically, one resident was observed with an occlusive dressing on the left side that was not dated, another resident had three undated dressings on the right lower extremity, and a third resident had a dressing on the lower left lateral area with no date, time, or initials. These findings were confirmed through interviews with staff, who acknowledged that the expectation is to label dressings with the date and initials after care is provided. Record reviews showed that all three residents had medical conditions requiring wound care, such as wounds on the lower extremities and other chronic diagnoses. The facility's own policy and staff interviews confirmed that labeling dressings is a required step in the care process. However, the observed failure to consistently label dressings as per policy demonstrated noncompliance with both facility procedures and professional standards of practice.
Discharge Executed While Appeal Pending and Without Adequate Planning
Penalty
Summary
A resident was discharged from the facility while an appeal of her discharge was still pending. The resident had received a 30-day discharge notice due to nonpayment and was informed of her right to appeal. Documentation shows that the resident filed her appeal on what the facility determined was the 11th day after notice, rather than within the 10-day window, and the facility proceeded with the discharge prior to the scheduled hearing date. Both the facility and the resident had received notice of the upcoming hearing, but the discharge was carried out before the appeal was heard. The resident had multiple complex medical conditions, including chronic hepatic failure, COPD, chronic respiratory failure, heart failure, lymphedema, morbid obesity, dysphagia, depression, and anxiety. At the time of discharge, she required significant assistance with transfers, was dependent on a sit-to-stand lift, and used a wheelchair as her primary mode of mobility. Therapy and social services notes indicated that not all necessary equipment, such as the sit-to-stand lift and upright walker, were available at her home at the time of discharge. The resident also reported not having a finalized schedule for home health services and expressed distress about being dependent on a male family member for personal care, which she found undignified and uncomfortable. Facility records and interviews confirm that the discharge was executed despite the pending appeal and without all recommended equipment and services in place. The facility's policy requires a safe, orderly, and planned discharge, including ensuring the resident's needs are met at the discharge location. The resident's care plan and therapy recommendations highlighted the need for specific equipment and support, which were not fully arranged at the time of discharge.
Non-compliance with Food Safety Standards
Penalty
Summary
The facility failed to ensure that kitchen staff adhered to professional standards for food service safety, as observed during a survey. On the initial tour of the kitchen, a staff member with facial hair was seen stirring a pot without a beard guard, and the Certified Dietary Manager (CDM) was observed without a hairnet. The CDM admitted to forgetting to wear a hairnet after a morning meeting and acknowledged that the staff member should have been wearing a beard guard. Later, another staff member with facial hair was observed without a beard guard while working over a large bowl, and the CDM had to instruct him to put one on, revealing a lack of awareness about the location of beard guards. Further observations revealed a dietary aide handling food without gloves. This staff member was seen opening a loaf of bread with bare hands and placing slices on a table without washing hands or wearing gloves. The Regional Dietitian intervened, instructing the staff member to discard the bread, wash hands, and wear gloves. The staff member admitted to sometimes neglecting to wear gloves due to being busy, despite previous education on the requirement. The facility's policy clearly prohibits contact between food and bare hands and mandates the use of hairnets and beard guards, which were not followed by the staff.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed in several instances. In one case, a Licensed Practical Nurse (LPN) was found with medication cups containing crushed medication in apple sauce stored in a medication cart drawer, which she intended to administer to residents. The cart also contained loose pills, an unlabeled insulin pen, and non-medical items such as tape and scissors. The LPN admitted to a lack of education regarding the proper storage of medications and was unaware of the need for regular cleaning of the medication carts. In another instance, a resident's room was found with multiple packets of peri-care ointment on the nightstand, without any self-administration assessment or orders for the resident to self-administer medications. Additional observations in other resident rooms revealed various medications and skin protectants left unsecured on nightstands, including wound cleanser, ketoconazole shampoo, and antifungal powder. The Director of Nursing (DON) confirmed that skin protectants should be kept in the treatment cart unless a self-administration assessment is completed. Furthermore, the medication storage room was found with an unlocked refrigerator for narcotics, containing an unsecured syringe of Lorazepam. The LPN/Unit Manager was unaware of the requirement to lock the narcotic box. The facility's policy mandates that all drugs and biologicals be stored in a safe, secure, and orderly manner, with specific guidelines for labeling, storage, and separation of medications, which were not adhered to in these instances.
Failure to Resolve Grievances on Call Light Delays
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances related to call light response times, as documented in the Resident Council Meeting Minutes over a period of four months. Concerns were repeatedly raised by the Resident Council regarding the need for more CNAs on the floor during mealtimes, particularly on weekends, and the delay in answering call lights, especially during the 3 p.m. to 11 p.m. shift. Despite these ongoing concerns, the grievance logs from June to November 2024 did not reflect any documented grievances from the Resident Council, indicating a lack of formal acknowledgment and resolution of these issues. Interviews with facility staff revealed inconsistencies in the grievance process. The Activities Director mentioned completing grievance forms for group issues but did not keep copies, while the Social Service Director described a process for logging and resolving grievances that was not effectively tracking recurring issues like call light delays. The Nursing Home Administrator was unaware of specific grievances and did not participate in trending grievances, leaving the Social Service Director to handle this task. The Resident Council President confirmed that the call light concerns remained unresolved, highlighting a disconnect between the facility's grievance policy and its implementation.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to provide wound care treatment in accordance with professional standards for four residents. Resident #413, who was cognitively intact, reported that her dressing had not been changed for four days despite orders for it to be changed every other day. The wound care nurse practitioner confirmed the dressing was overdue for a change and noted issues with the dressing not being changed as ordered. Resident #42, also cognitively intact, had undated dressings on both feet that were not changed as per the physician's orders. Observations revealed the dressings were soiled and unchanged over several days, despite being signed off as completed in the Treatment Administration Record. The resident expressed dissatisfaction with the timing of the dressing changes, indicating they were not done daily as required. Resident #263 expressed concerns about her wound treatment, stating that her left heel had been bleeding and the bandage had not been changed since it was applied. Observations confirmed the bandage was dated several days prior, and the Treatment Administration Record showed infrequent dressing changes. Resident #264 had an undated dressing on the left forearm with no corresponding treatment orders, and neither the resident nor the family was aware of the reason for the dressing. The Director of Nursing acknowledged that dressings should be dated and orders followed.
Failure to Implement Smoking Safety Precautions
Penalty
Summary
The facility failed to implement safety precautions for a resident who was identified as needing supervision while smoking. The resident, who was moderately cognitively impaired with a BIMS score of 11/15, was observed with cigarettes and a lighter in her possession on multiple occasions. Despite the facility's policy requiring that residents without independent smoking privileges should not keep smoking articles, the resident was allowed to hold her smoking supplies. This was contrary to the smoking assessments and care plan, which indicated that the resident needed supervision and that the facility should store her smoking supplies. Interviews with staff confirmed that the resident was a smoker who required supervision, yet she was still in possession of her smoking materials. The facility's smoking policy, which mandates safe smoking practices and the storage of smoking supplies for residents needing supervision, was not adhered to. The Nursing Home Administrator acknowledged the assessments indicating the need for supervision, yet the resident continued to have access to her smoking supplies, highlighting a lapse in the implementation of the facility's safety protocols.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to ensure the timely and appropriate change of a central line dressing for a resident, leading to a deficiency in care. Observations revealed that the dressing on the resident's peripherally inserted central catheter (PICC) was dated 10/27/24, despite the requirement for weekly changes. The resident, who was receiving intravenous antibiotics for osteomyelitis, was unable to confirm when the dressing was last changed. Further observations noted remnants of a sticker on the dressing, and a new date of 11/20 was written on it by a staff member without evidence of a proper dressing change. The resident's medical history included orthopedic aftercare following surgical amputation, acute hematogenous osteomyelitis, and atherosclerosis with gangrene. The facility's policy required PICC line dressings to be changed within 24 hours of a new resident's arrival and then every seven days, or as needed if the dressing was soiled or loose. However, the dressing was not changed as per these guidelines, and the staff member involved acknowledged marking the dressing with a new date without confirming a proper change had occurred. This oversight was contrary to the facility's policy aimed at preventing catheter-related infections.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to accommodate food preferences for two residents, leading to deficiencies in meal service. Resident #90, who has a controlled carbohydrate diet due to end-stage renal disease and type 1 diabetes, was observed receiving meals that did not align with their dietary restrictions. Despite having specific meal preferences documented, such as no rice or potatoes and a preference for double vegetables, Resident #90 was served rice and was not provided with alternative options. This resident expressed frustration over not receiving the correct meals and reported weight loss, relying on protein shakes for nutritional needs. The care plan for Resident #90 included monitoring for signs of malnutrition and serving the diet as ordered, which was not adhered to. Similarly, Resident #263 repeatedly requested meals without gravy but continued to receive food with gravy, which they refused to eat. The Certified Dietary Manager acknowledged the issue, noting that resident choices are documented daily and meetings are held to discuss preferences. However, the dietary staff failed to follow the tray tickets, resulting in non-compliance with resident preferences. The facility's policy on resident food preferences emphasizes assessing and communicating individual preferences upon admission and creating a care plan if the resident is dissatisfied, which was not effectively implemented in these cases.
Infection Control Deficiencies in Respiratory and Contact Precautions
Penalty
Summary
The facility failed to ensure proper infection control practices across two units, as evidenced by several observations and interviews. In one instance, a respiratory mask was left uncovered on a bedside table in the room of a resident with chronic obstructive pulmonary disease and chronic respiratory failure. The resident confirmed that the mask was routinely left uncovered by staff. Additionally, during medication administration, a nurse was observed using a glucometer and glucose test strips without proper labeling or cleaning between residents, despite the facility having enough glucometers for each resident. Further observations revealed an ice scoop left uncovered on a cart in a hallway, which was confirmed by the Director of Nursing (DON) as against facility policy. The DON also acknowledged that respiratory masks should be stored in a bag or box when not in use. The facility's infection prevention and control policies were not adhered to, as evidenced by the improper handling of clean linens and the lack of cleaning of glucometers between uses. Another deficiency was noted in the handling of a resident suspected of having Clostridium Difficile (C-diff). The resident, who had complained of loose stools, was not placed on contact precautions, and no signage was posted on the room door to indicate the need for precautions. The resident was also sharing an IV medication pole with another resident. The facility's policy stated that transmission-based precautions should be initiated when a resident shows signs of a transmissible infection, but this was not followed, as confirmed by the acting Infection Preventionist and the Nursing Home Administrator.
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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