Viera Del Mar Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Viera, Florida.
- Location
- 2355 Vidina Drive, Viera, Florida 32940
- CMS Provider Number
- 106123
- Inspections on file
- 29
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Viera Del Mar Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to consistently provide and document ordered wound and dermatologic treatments for two residents. One resident with a pressure ulcer and lower leg abrasions had physician orders for specific cleansing and dressings, as well as Dakins and zinc oxide applications, yet the TAR showed multiple missed treatments across several shifts. Another resident with tinea pedis had a dermatology order for daily Ketoconazole cream to both feet, but interviews with multiple LPNs revealed conflicting accounts about application, an unopened tube of cream, lack of refills, and uncertainty about prior use, while family reported the resident did not receive the cream for several days after admission.
Multiple residents experienced prolonged call light response times and unmet care needs due to insufficient nursing staff. Residents with recent hospitalizations, pain management needs, and respiratory conditions reported significant delays in receiving assistance, while staff described heavy workloads and frequent understaffing. Resident Council discussions and facility records confirmed ongoing concerns about staffing shortages and their impact on timely care.
A resident with multiple psychiatric and neurological diagnoses was administered several classes of medications, including antidepressants, anticonvulsants, antipsychotics, antibiotics, and opioids. The MDS assessment failed to accurately document all medication classes received during the lookback period, omitting antipsychotic, antidepressant, and opioid medications, despite facility policy requiring comprehensive and accurate assessments.
A resident with a history of SMI and multiple psychiatric diagnoses experienced significant behavioral changes and new mental health diagnoses after hospital readmission. Despite ongoing psychiatric symptoms and interventions, the facility did not complete or update the required Level I PASARR, and key documentation was left incomplete. Staff interviews confirmed the oversight, and there was no policy in place to clarify responsibility for PASARR updates.
An LPN failed to remove gloves and perform hand hygiene when exiting and reentering a resident's room during the setup of an IV iron infusion. The LPN handled equipment and moved a trash can while wearing the same gloves, contrary to infection control protocols. The DON confirmed that staff are expected to remove gloves and perform hand hygiene before leaving a resident's room, and that all staff receive related education.
The facility experienced repeated deficiencies in the accuracy of medical record documentation due to insufficient monitoring and oversight by the QAPI team. Despite providing education to nursing staff and planning audits, the same issue was cited in multiple surveys, and the Administrator was not aware of previous deficiencies, indicating a lack of effective tracking and follow-through on corrective actions.
A resident with multiple medical conditions was discharged without a complete written discharge summary or medication list, and key sections of the discharge documentation were left blank. The resident's designated representative was not notified in advance, and there was no evidence that discharge instructions or medications were provided. Staff interviews confirmed the discharge process was not properly followed, and required documentation and communication were lacking.
A resident with complex medical needs was discharged without complete documentation of their discharge plan, disposition, and ADLs. Key sections of the Discharge Summary were left blank, including areas related to skin evaluation, treatments, cognitive/psychosocial status, and medication reconciliation. There was no evidence that the Discharge Summary was provided to or signed by the resident or staff, and CNA documentation of ADLs was incomplete across multiple shifts. The DON acknowledged these documentation gaps, which did not meet federal requirements for medical record maintenance.
A resident with severe cognitive impairment and a history of falls was not provided with adequate supervision or effective fall prevention measures, resulting in a fall that caused a facial laceration and nasal fracture. Despite being identified as a high fall risk, the facility did not increase supervision or implement specific interventions, and staff were not directed to check on the resident within specific timeframes. The facility's Falling Leaf Program was not effectively communicated or implemented, contributing to the resident's injury.
A resident with severe cognitive impairment and multiple medical conditions experienced several falls, including a significant fall resulting in a head injury, at an LTC facility. Despite being identified as a high fall risk, the resident's care plan lacked adequate interventions, and the facility failed to report the incidents to the proper authorities. Staff interviews revealed that the care plan did not include necessary fall prevention measures, and the facility did not consider the incident reportable.
A resident with severe cognitive impairment and a history of impulsivity fell from her wheelchair outside the facility, sustaining a facial laceration and head injury. Despite being a known fall risk, she was left unsupervised, leading to the incident. Staff interviews revealed inconsistencies in the facility's investigation, and the facility's documentation did not align with staff statements. Additionally, the facility failed to identify a nasal fracture noted in the hospital records.
A resident returned to the facility after a hospital visit with a discharge packet that included important medical information, such as a possible nasal fracture. However, the facility failed to scan these records into the EHR, resulting in incomplete documentation. Staff interviews revealed that the records were misplaced, and the attending physician was not informed of the fracture, indicating a breakdown in communication and record-keeping processes.
A resident with liver cirrhosis and metabolic encephalopathy suffered harm due to the facility's failure to administer prescribed medications and monitor her condition. Despite physician orders for Lactulose and Rifaximin, the facility did not provide these medications as required, leading to elevated ammonia levels and a decline in the resident's health. Family concerns and requests for hospital transfer were not promptly addressed, resulting in the resident's hospitalization.
A resident with liver cirrhosis did not receive prescribed Rifaximin due to the facility's failure to complete authorization for this high-cost medication. LPNs documented administering the drug despite its unavailability, with some borrowing from another resident's discontinued supply, violating facility policy. The management was unaware of these issues until identified by surveyors.
The facility failed to serve palatable food at the appropriate temperature to residents in two halls. Several residents complained about cold food, and observations showed that lunch trays were covered with clear plastic covers instead of insulated lids and delivered via a non-insulated cart. The Chef and CDM confirmed that food temperatures were taken 30 minutes before plating, and the facility lacked insulated plate lids and a thermal transport system, leading to the deficiency.
A resident with spinal stenosis, muscle weakness, and rheumatoid arthritis did not receive the prescribed restorative care for range of motion, including splint application, as ordered. Despite the resident's compliance and desire for the splint, it was not applied on several occasions. The Director of Rehabilitation and the Restorative Nurse confirmed the oversight, and the DON acknowledged the resident's cognitive status, confirming the splint should have been applied as ordered.
A resident with COPD was found to have their oxygen concentrator set at 4 liters per minute instead of the prescribed 2 liters. Neither the resident nor their family adjusted the flow rate, indicating a lapse in staff responsibility. Both an LPN and the DON confirmed the discrepancy and acknowledged the importance of adhering to physician orders for oxygen therapy.
Failure to Provide and Document Ordered Wound and Dermatologic Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide timely, consistent, and properly documented dermatologic and wound treatments as ordered and care planned for two residents. For one resident admitted for nerve pain, the care plan identified a pressure ulcer on the buttocks and risk for skin impairment, with interventions including weekly skin checks, measurements of the wound, nutritional support, preventive skin treatments, and prompt incontinence care. Physician orders directed cleansing of bilateral lower legs with normal saline, patting dry, and wrapping with a dry dressing every evening shift, as well as cleansing an area between the buttocks with 1/4 Dakins and applying zinc oxide every shift. Review of the Treatment Administration Record (TAR) showed missing treatments for the lower leg wound care order on multiple dates and missing treatments for the buttocks wound care order on several shifts. Further review showed an additional physician order for wound care to bilateral lower legs every dayshift, also with missed treatments documented on the TAR. The wound care nurse stated her responsibilities were limited to residents with stage three or greater pressure wounds, while "cart nurses" were responsible for less severe wounds and weekly wound assessments. An LPN identified as a cart nurse reported that she completed wound assessments weekly and provided wound treatments when ordered, and that she always completed treatments by the end of her shift or notified the next shift or manager if unable to do so. Despite these statements, the TAR documentation reflected that ordered treatments for this resident’s wounds were not consistently completed as prescribed. For another resident admitted with a several-week history of a rash on both feet, a dermatology consultation diagnosed tinea pedis and prescribed 2% Ketoconazole cream to be applied daily to both feet until resolved. On interview, the dermatologist confirmed the daily application order and stated that failure to apply the cream as ordered could result in worsening fungal infection and secondary complications. Multiple LPNs gave conflicting information regarding the use and availability of the Ketoconazole cream: one LPN initially stated she applied the cream to the resident’s belly button, then corrected herself to say it was for the feet, and presented an unopened tube dated with the resident’s name, explaining that a previous tube had been thrown away that morning. Other LPNs stated that only one tube had been obtained from the pharmacy, that it had not been refilled, and that the tube should last approximately two and a half to three weeks if used as ordered. Family members reported the resident had not received the prescribed cream for several days after admission and expressed concern that the ordered daily treatment had been missed.
Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs and preferences of residents, as evidenced by prolonged call light response times and unmet care needs for multiple residents. Observations revealed that call lights remained unanswered for extended periods, with one resident waiting 25 minutes and another 20 minutes. Residents were observed calling out for assistance, and staff were not present in the hallways during these times. One resident, who had recently returned from the hospital after an amputation, was left waiting for pain medication, reporting severe pain and a significant delay since his last dose. His care plan required timely pain management, but the delay in response resulted in unmanaged pain. Another resident, dependent on staff for transfers, reported waiting approximately 30 minutes for assistance to return to bed and described routine delays due to staffing shortages. She expressed frustration with the long wait times and noted that CNAs were overworked, handling multiple responsibilities simultaneously. A third resident, with a history of respiratory issues and anxiety, also experienced delays in receiving her inhaler before scheduled therapy, leading to increased anxiety and physical symptoms. She noted that long wait times for call light responses were consistent regardless of shift or day. Staff interviews confirmed that call lights were often left unanswered due to heavy workloads and insufficient staffing, particularly during night shifts and meal service times. CNAs reported being assigned to multiple residents with high care needs, making it difficult to respond promptly to all requests. Resident Council meeting minutes and interviews with the Resident Council President highlighted ongoing concerns about staffing shortages, which had been repeatedly discussed without resolution. Facility policies required prompt call light response, and the facility assessment acknowledged the need for staffing adjustments based on resident acuity and care needs, but these standards were not met in practice.
Inaccurate MDS Medication Documentation
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the prescribed medications for a resident with multiple complex diagnoses, including multiple sclerosis, major depressive disorder, anxiety, seizures, bipolar disorder, brief psychotic disorder, and psychosis. After being readmitted from an acute care hospital, the resident was prescribed several medications, including antidepressants, anticonvulsants, antipsychotics, antibiotics, and opioids. Review of the Medication Administration Report (MAR) confirmed that these medications were administered during the seven-day lookback period relevant to the MDS assessment. However, the MDS assessment completed for the resident did not accurately document all the medication classes received, specifically omitting antipsychotic, antidepressant, and opioid medications in Section N. The MDS Lead confirmed that the assessment should have included these drug classes and explained that the assessment was completed by a new MDS Coordinator. Corporate audits of MDS assessments were performed only on a random basis, and the facility's policy required comprehensive and accurate assessments using the Resident Assessment Instrument (RAI).
Failure to Complete PASARR After Significant Change in Mental Condition
Penalty
Summary
The facility failed to ensure the completion and accuracy of a Level I Preadmission Screening and Resident Review (PASARR) following the readmission of a resident with a diagnosis of Serious Mental Illness (SMI) after a significant change in her mental condition. The resident, who had a history of multiple sclerosis, major depressive disorder, anxiety, and seizures, was readmitted from an acute care hospital and subsequently developed additional psychiatric diagnoses, including bipolar disorder, brief psychotic disorder, and psychosis. Despite these new diagnoses and significant behavioral changes, there was no evidence that a new Level I PASARR was completed after her readmission or following the onset of new psychiatric symptoms. The resident exhibited a range of severe behavioral symptoms, including hallucinations, delusions, impulsivity, aggression, resisting care, and socially inappropriate behaviors. Progress notes documented multiple incidents where the resident called 911, refused medications, food, and drink, and required emergency interventions such as the administration of psychotropic medications and involuntary psychiatric holds under state law. The medical record also showed ongoing psychiatric evaluations and medication adjustments due to persistent psychosis, agitation, and mood instability. Despite these significant changes, the PASARR documentation in the record was incomplete, with key sections left blank and no indication that a Level II evaluation was considered or initiated. Interviews with facility staff, including the LPN, Social Services Assistant, DON, and Administrator, confirmed that the PASARR was not reviewed or resubmitted after the resident's significant behavioral changes and new psychiatric diagnoses. The DON acknowledged that a new PASARR should have been completed in such circumstances, and the Administrator admitted the omission was an oversight. Additionally, the facility lacked a policy defining which staff member was responsible for updating PASARRs, and no behavioral health or behavior management policy was provided upon request.
Failure to Follow Hand Hygiene and PPE Protocol During IV Infusion
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper hand hygiene and personal protective equipment (PPE) protocols while assisting a resident with an intravenous (IV) infusion. The resident, who had a midline catheter for anemia treatment and multiple diagnoses including metabolic encephalopathy, type 2 diabetes, stroke, and weakness, was observed during the setup of an iron infusion. The LPN exited the resident's room wearing gloves, used scissors from the medication cart to open an IV-line package outside the room, and then reentered the room still wearing the same gloves. Inside, the LPN continued to handle the IV line and moved a trash can without changing gloves or performing hand hygiene. The LPN later confirmed that she did not remove her gloves or perform hand hygiene when leaving and reentering the resident's room, acknowledging that this was a violation of infection control protocol. The Director of Nursing (DON) stated that staff are expected to remove gloves and perform hand hygiene before exiting a resident's room. Facility records indicated that all staff receive infection control and hand hygiene education upon hire and annually.
Repeated Deficiency in Medical Record Documentation Due to Inadequate QAPI Oversight
Penalty
Summary
The facility failed to implement its Quality Assurance and Performance Improvement (QAPI) policies to ensure thorough monitoring and tracking of previously identified areas of concern, specifically regarding the accuracy of medical record documentation. Despite having a QAPI program with objectives to monitor and evaluate corrective actions, the facility had repeated deficiencies at F842, related to medical record accuracy, identified during complaint surveys. The review of documentation showed that education was provided to nursing staff and audits were planned, but the same deficiency was cited again in subsequent surveys, indicating that the measures taken were not effectively monitored or sustained. During interviews, the Administrator reported limited participation in QAPI meetings since starting at the facility and was unaware of the previous deficiencies related to medical records documentation. The repeated citation of F842 demonstrated insufficient auditing and oversight by the QAPI team, as the facility did not ensure that prior improvement measures were realized and maintained, leading to ongoing non-compliance with documentation standards.
Incomplete Discharge Documentation and Notification
Penalty
Summary
A deficiency occurred when the facility failed to provide a complete written discharge summary and a list of medications to a resident upon discharge. The resident, who had diagnoses including nontraumatic subacute subdural hemorrhage, COPD, type 2 diabetes, repeated falls, and mobility issues, was readmitted to the facility and later discharged home. The discharge summary form in the medical record was incomplete, with several sections left blank, including skin evaluation, treatments, cognitive/psychosocial status, ADLs, sensory, dietary, rehabilitation services, and education/acknowledgement. The section for instructions after discharge was only partially completed, and the medication list, pharmacy details, and documentation of scripts provided were not addressed. There was no evidence that the discharge summary was given to the resident or signed by either the resident or staff, nor was there documentation of medication reconciliation or confirmation that medications were provided upon discharge. Interviews with facility staff revealed a lack of documentation and communication regarding the discharge process. The resident's sister, who was listed as the health care surrogate and POA, reported she was not notified in advance of the discharge and only received a call after the resident had left. Staff interviews indicated that the discharge was not planned according to standard procedures, and there were no progress notes or documentation of discharge planning or education provided to the resident. The Social Services Assistant and DON confirmed that the discharge summary was incomplete and not signed, and that the physician order for discharge and referral to home health were not completed until the day after the resident left. Attempts to contact the nurses and CNAs who worked during the discharge period were unsuccessful, and there was no documentation in the progress notes regarding the discharge. The facility's policy required an effective discharge process, including preparation of residents for transition and provision of necessary documentation. However, the process was not followed in this case, as evidenced by the incomplete discharge summary, lack of medication documentation, and absence of communication with the resident's designated representative. The discharge occurred without proper planning, documentation, or notification, resulting in a failure to meet regulatory requirements for resident discharge.
Incomplete Discharge Documentation and ADL Records
Penalty
Summary
The facility failed to accurately document the discharge plan, disposition, and Activities of Daily Living (ADLs) for a resident who was readmitted with multiple diagnoses, including a subacute subdural hemorrhage, COPD, diabetes, repeated falls, and mobility issues. The resident's quarterly MDS assessment indicated an active discharge plan for return to the community, but the Discharge MDS later documented a planned discharge home with return not anticipated. The Discharge Summary form was incomplete, with several sections left blank, such as Skin Evaluation, Treatments, Cognitive/Psychosocial, ADLs/Functional Status, Sensory, Dietary, Rehabilitation Services, and Education/Acknowledgement. The Instructions After Discharge section was only partially completed, and there was no documentation of medication reconciliation, pharmacy details, or confirmation that medications or scripts were provided upon discharge. Additionally, there was no evidence that the Discharge Summary was given to or signed by the resident or staff. Review of the resident's physician orders and progress notes did not reveal any entries regarding discharge planning, education provided, or disposition of medications. Documentation of ADL tasks by CNAs was found to be incomplete, with multiple shifts showing blank entries for care provided. The DON confirmed that staff were expected to document care as close as possible to the time it was performed and acknowledged the incomplete and unsigned Discharge Summary. The facility's Medical Records policy required maintenance of records per federal requirements, which was not met in this instance.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and implement appropriate interventions to prevent falls for a resident with a history of repeated falls, resulting in actual harm. The resident, an elderly female with severe cognitive impairment and multiple medical conditions, was admitted to the facility with a history of impulsivity and a need for substantial assistance with mobility. Despite being identified as a high fall risk, the facility did not increase supervision or implement effective fall prevention measures after the resident experienced multiple falls. The resident had a history of falls, including four incidents in September, none of which were witnessed by staff. On one occasion, the resident was found on the floor with a head laceration after attempting to transfer herself. Despite these incidents, the facility did not implement increased supervision or specific interventions to address the resident's fall risk. The resident's care plan lacked detailed instructions for supervision, and staff were not directed to check on her within specific timeframes. The facility's failure to provide one-on-one supervision or frequent checks contributed to the resident's fall on October 5th, resulting in a facial laceration and a nasal fracture. Interviews with staff revealed that the resident was known to be impulsive and frequently attempted to move around unsupervised. Staff expressed concerns about the resident's safety and the difficulty of monitoring her while attending to other residents. Despite these concerns, the facility did not provide additional supervision or implement effective fall prevention strategies. The facility's Falling Leaf Program, intended to alert staff to high fall risk residents, was not effectively communicated or implemented, and the resident's care plan did not reflect the necessary interventions to prevent falls.
Failure to Report Possible Neglect After Resident's Falls
Penalty
Summary
The facility failed to report possible neglect for a resident who experienced multiple falls, including a significant fall that resulted in a head injury and a possible nondisplaced nasal bone fracture. The resident, an elderly female with severe cognitive impairment and multiple medical conditions, was admitted to the facility with a history of acute respiratory failure, sepsis, and dementia, among other diagnoses. Despite being identified as a high fall risk, the resident's care plan lacked adequate interventions to prevent falls, such as frequent checks or a fall program. The resident experienced several falls in September, none of which were witnessed by staff, and the facility did not report these incidents to the proper authorities. On one occasion, the resident was found alone on the patio, having fallen from her wheelchair, resulting in facial lacerations and altered consciousness. The facility's investigation concluded that the resident was independent with wheelchair propulsion and did not consider the incident reportable, as they believed the resident was supervised in an enclosed area. Interviews with facility staff revealed that the resident's care plan did not include the Falling Leaf Program or frequent checks, despite being a high fall risk. The facility's Director of Nursing and Nursing Home Administrator did not report the incident to the state agency, as they believed the care plan was followed and were unaware of the possible fracture. The facility's standards and guidelines define neglect as the failure to provide necessary goods and services to avoid harm, yet the facility did not report the incident as neglect.
Failure to Investigate and Supervise Leads to Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate and identify possible neglect for a resident who was severely cognitively impaired and had a history of impulsivity. The resident, who required substantial assistance for mobility and activities of daily living, was found outside alone and had fallen from her wheelchair, sustaining a facial laceration and a head injury. Despite being a known fall risk, the resident was left unsupervised, leading to the incident. Staff interviews revealed inconsistencies in the facility's investigation. Certified Nursing Assistants (CNAs) and a Licensed Practical Nurse (LPN) provided conflicting accounts of the supervision and checks conducted on the resident. The CNAs were expected to conduct 15-minute checks due to the resident's severe dementia and fall risk, but the resident was left alone outside, resulting in the fall. The facility's documentation and investigation did not align with the staff's statements, indicating a lack of thorough investigation and communication. The facility's investigation documents were incomplete, missing statements from key staff members involved in the incident. Additionally, the facility's review of the resident's emergency room visit failed to identify a nasal fracture, which was noted in the hospital records. The Director of Nursing (DON) and the Nursing Home Administrator acknowledged the discrepancies in the investigation and the lack of awareness of the resident's full medical condition post-fall.
Incomplete Medical Records for Resident Post-Hospital Discharge
Penalty
Summary
The facility failed to maintain a complete and readily accessible medical record for a resident who was reviewed for administration. The resident, an elderly female, was admitted to the facility with multiple diagnoses including acute respiratory failure, sepsis, and dementia. After a fall resulting in a head injury, she was transported to the hospital and returned with a discharge packet that included prescriptions and test results. However, the facility was unable to locate these records, which included a CT scan indicating a possible nasal fracture. Interviews with staff revealed that the hospital discharge packet was placed in a drawer at the nurse's station but was not scanned into the electronic health record (EHR) as required. The Medical Records Clerk confirmed that the records were not scanned and were missing. The Director of Nursing and other staff members acknowledged the importance of having complete records for clinical review but were unable to explain the absence of the records. The attending physician and Medical Director were not informed of the nasal fracture, highlighting a communication breakdown in the facility's process for handling hospital discharge information. The deficiency was further compounded by the lack of follow-up actions to retrieve the missing records. Despite the facility's protocol for reviewing hospital discharge records in morning meetings, the records were not available for review, and no one had requested them from the hospital. This oversight resulted in incomplete documentation and a lack of awareness among the clinical team regarding the resident's nasal fracture, which was crucial for her ongoing care and monitoring.
Failure to Administer Medications and Monitor Condition Leads to Resident Harm
Penalty
Summary
The facility failed to provide care and services according to professional standards of practice, resulting in actual harm to a resident with liver cirrhosis and metabolic encephalopathy. The resident was admitted with physician orders for Lactulose and Rifaximin to manage hyperammonia, but the facility did not administer these medications as prescribed. The resident's ammonia levels were not adequately monitored, and there was a delay in responding to elevated ammonia levels, leading to a deterioration in the resident's condition. The resident exhibited symptoms of high ammonia levels, such as nausea, confusion, and lethargy, which were not promptly addressed by the facility staff. Despite family members expressing concerns and requesting hospital transfer, the facility delayed action, resulting in the resident's condition worsening to the point of requiring hospitalization. The facility's documentation did not accurately reflect the resident's declining condition, and there were discrepancies in medication administration records. Interviews with facility staff revealed communication breakdowns and a lack of timely response to the resident's changing condition. The facility's pharmacy records indicated that only a limited supply of Rifaximin was dispensed, and there was no follow-up to ensure the resident received the necessary medication. The facility's failure to adhere to medication orders and promptly address the resident's symptoms contributed to the resident's hospitalization and harm.
Deficiency in Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident with liver cirrhosis and metabolic encephalopathy, leading to a deficiency in medication administration. The resident was prescribed Lactulose and Rifaximin to manage hyperammonia, a condition associated with hepatic encephalopathy. However, the facility did not ensure the availability of Rifaximin, resulting in missed doses over several days. The medication was categorized as high-cost, requiring special authorization, which was not completed by the facility, leading to a lack of supply. Multiple Licensed Practical Nurses (LPNs) documented administering Rifaximin despite its unavailability, with some admitting to borrowing the medication from another resident's discontinued supply. This practice was against the facility's policy, which prohibits administering medications prescribed for one resident to another. The facility's management was unaware of the medication shortage and the inappropriate borrowing practice until it was identified by the State Survey Agency staff. The facility's investigation revealed that the pharmacy had sent multiple requests for authorization to dispense additional Rifaximin, but these were not returned by the facility. The Assistant Director of Nursing confirmed that a card of Rifaximin with 17 pills was found during an audit, which should have been returned to the pharmacy. The facility's failure to manage medication orders and returns properly, along with the inappropriate actions of the nursing staff, contributed to the deficiency in pharmaceutical services.
Deficiency in Serving Palatable Food at Appropriate Temperature
Penalty
Summary
The facility failed to serve palatable food at the appropriate temperature to residents in two of its halls, specifically the 300 and 600 halls. During the recertification survey, several residents complained about receiving cold food. Observations revealed that the lunch trays for the 600 hall were covered with clear plastic covers instead of insulated dome lids, which were used for other trays. The lunch trays were delivered via a non-insulated, non-heated metal cart, and the food was found to be lukewarm and not palatable by the surveyors. The Chef and Certified Dietary Manager confirmed that the steam table temperatures were taken 30 minutes before the first meal was plated, and the food met temperature standards at that time. However, the facility was missing 25-30 insulated plate lids, and it did not use a thermal food transport system to maintain hot food temperatures during meal service. This contributed to the deficiency of serving cold food to residents, as evidenced by the complaints and observations made during the survey.
Failure to Implement Restorative Care for Resident's Range of Motion
Penalty
Summary
The facility failed to implement the recommended restorative care for a resident, leading to a deficiency in maintaining and improving the resident's range of motion. The resident, who was admitted with spinal stenosis, muscle weakness, and rheumatoid arthritis, had an active physician's order for a restorative nursing program that included passive range of motion and splint application for his left hand. Despite the resident's compliance and desire to have the splint applied, observations and interviews revealed that the splint was not applied on several occasions, including specific dates in July. The resident reported that the splint was supposed to be applied daily but had not been applied several times over the past week and on specific days. The Director of Rehabilitation and the Restorative Nurse confirmed that the resident was to have the splint applied 4-5 days a week for 4-6 hours each time, as prescribed. However, the task report showed that the splint was not applied on multiple days, and the resident had not refused the application. The Director of Nursing acknowledged the resident's cognitive status and confirmed that the splint should have been applied as ordered. The facility's Restorative Nursing Services Standards and Guidelines emphasize promoting the resident's optimum function through a restorative nursing program, which was not adhered to in this case.
Failure to Maintain Prescribed Oxygen Flow Rate
Penalty
Summary
The facility failed to maintain the prescribed oxygen flow rate for a resident with chronic respiratory conditions, including COPD. The resident was admitted with a physician's order for continuous oxygen at 2 liters per minute via nasal cannula. However, during an observation, the oxygen concentrator was found to be set at 4 liters per minute. The resident and a family member confirmed that neither had adjusted the flow rate, indicating a lapse in staff responsibility. Licensed Practical Nurse (LPN) A and the Director of Nursing both acknowledged the discrepancy between the physician's order and the actual oxygen flow rate. They confirmed that it was the nurse's responsibility to ensure the oxygen settings matched the physician's order and to monitor these settings regularly. The facility's guidelines also emphasized the importance of adhering to physician orders for oxygen therapy. This oversight could potentially lead to respiratory distress or oxygen toxicity, particularly in a resident with COPD.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
