West Delray Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Delray Beach, Florida.
- Location
- 16200 S Jog Road, Delray Beach, Florida 33446
- CMS Provider Number
- 106005
- Inspections on file
- 22
- Latest survey
- June 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at West Delray Nursing & Rehab Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and intact cognition did not have grievances documented or resolved after the resident's son reported concerns about care, medications, and malfunctioning equipment to facility administrators. Despite the facility's policy requiring documentation and follow-up of grievances, staff could not explain the absence of these complaints in the official records.
A resident with multiple chronic conditions was admitted and did not receive several physician-ordered medications for immediate care until the tenth day of their stay. Although recommendations and telephone orders were made at admission, these medications were not documented in the medical record or MAR, and facility staff could not explain the delay.
The facility failed to follow physician orders, resulting in a medication error rate of 32%, affecting multiple residents. The errors were identified during a medication pass observation signed by the Consultant Pharmacist for an LPN, where medications were not administered within the required time frame as per facility policy.
The facility's medication error rate was 32%, exceeding the acceptable threshold of 5%. Errors were observed in the timing of medication administration, with staff overwhelmed by additional duties. Management was aware of the delays, and some staff had attended in-services, but issues persisted.
The facility's QAPI program failed to correct medication errors, with 10 errors observed out of 31 opportunities, affecting four residents. Despite re-education and monitoring efforts, the medication error rate exceeded the acceptable threshold, indicating ineffective implementation of corrective measures.
The facility failed to ensure call lights were within reach for two residents, one with intact cognition and another with severe cognitive impairment. Both residents were at risk for falls, and the call lights were observed out of reach, contrary to care plan interventions and facility policy. A CNA confirmed the importance of keeping call lights accessible and responding promptly.
A facility failed to update a resident's Advanced Directives status, resulting in a deficiency. The resident had a DNR order, but this was not reflected in the physician orders or EHR. Staff interviews revealed inconsistencies in the process of documenting and updating Advanced Directives, contributing to the oversight.
A resident with cognitive impairment and a history of falls was found with significant injuries after an unwitnessed fall. The facility failed to report the incident to the state agency, as required by policy and law. The DON and Administrator did not recognize the fall as reportable, assuming it was due to the resident's behavior. The investigation was incomplete, lacking documentation of corrective actions and follow-up, and staff interviews revealed a lack of understanding of reporting requirements.
A resident with cognitive impairment and multiple diagnoses did not receive wound care as per physician orders, with inconsistencies in dressing changes and documentation. Observations showed outdated dressings, and interviews confirmed lapses in care and communication among staff.
A resident with cognitive impairment and a history of falls did not receive a Fall Risk Assessment upon admission, leading to an unwitnessed fall with significant injuries. The facility failed to document or investigate the incident properly, and there was no evidence of follow-up or reporting to the state. Staff interviews indicated the resident was often confused and attempted to ambulate without assistance, yet interventions were not effectively implemented.
A resident with a history of neurogenic bladder was observed with an unsecured Foley catheter, and improper catheter care was provided by a CNA. The CNA failed to perform hand hygiene, did not provide privacy, and used incorrect cleaning techniques. The catheter tubing was placed under the resident's leg without an anchor, contrary to the care plan. The DON confirmed these deficiencies during an observation.
Two residents experienced significant weight loss that was not addressed in a timely manner, leading to deficiencies in nutritional care. One resident lost 7.10% of their weight over a month, and another lost 18% over two months. Documentation showed inconsistent recording of nutritional supplement intake, with no percentage of consumption noted. Staff interviews revealed limitations in the documentation system, contributing to the deficiencies.
A facility failed to ensure timely physician visits for a resident with severe cognitive impairment. The facility's policy requires monthly visits for the first 90 days and every 60 days thereafter. However, there was no documentation of visits by the attending physician over a three-month period. The physician stated that he alternates visits with an NP, who documents their collaboration, but he does not author any notes himself. The DON acknowledged the lack of documentation.
The facility failed to meet the minimum required nursing and CNA staffing levels for 3 out of 28 days. The CNA daily average fell below 2.0 on two occasions, and the nursing daily average was below 1.0 on two occasions. Interviews with the Staffing Coordinator and DON confirmed the deficiency, particularly on weekends.
The facility failed to post complete nurse staffing information for four days, listing only hours worked without specifying the number of nursing staff or the facility name. Observations showed consistent omissions, and interviews revealed a lack of clarity in the posting process, with the Staffing Coordinator not including staff numbers on the postings.
The facility failed to comply with the 14-day limit for PRN psychotropic medications for three residents, lacking documented rationale for extending orders. A resident with anxiety and depression was prescribed Alprazolam for 30 days without justification. Another resident with Generalized Anxiety Disorder had a PRN order for Lorazepam extended without documentation. A third resident with anxiety and depression received Alprazolam frequently over three months without a documented start or end date. The Consultant Pharmacist and DON confirmed the non-compliance.
The facility's medication error rate was 13.33%, exceeding the acceptable 5% threshold. Two residents experienced medication administration errors, including late administration and improper handling of medications. Staff interviews revealed a lack of understanding of medication administration policies, contributing to the errors.
The facility failed to properly supervise and store medications for two residents, with OTC medications found unattended in their rooms without physician orders or care plans for self-administration. Additionally, medication and treatment carts were left unlocked and unattended by staff, compromising medication security.
The facility failed to meet food safety standards during kitchen inspections, with issues such as improper food storage, inadequate sanitation, and equipment maintenance problems. Observations included undated and expired food items, sanitation buckets with no solution, and a dishwasher not reaching required temperatures.
The facility failed to maintain accurate clinical records for two residents. A resident with Parkinson's Disease did not receive documented wound care as ordered, with discrepancies in dressing dates and no evidence of treatment refusal. Another resident with severe cognitive impairment had medical notes inaccurately listing a Nurse Practitioner as a Physician, with no documented physician visits. These issues highlight deficiencies in documentation and adherence to care protocols.
The facility failed to follow CDC guidelines for infection control, as a CNA used the same gloves for multiple tasks with a resident, and an RN did not disinfect vital signs equipment between uses on two residents. This breach in protocol exposed residents to potential infection risks.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to appropriately respond to and resolve grievances for one resident, as required by its own grievance policy. The policy states that grievances may be voiced verbally to staff and must be documented on the facility grievance report. However, a review of the grievance records for May did not show any documentation of complaints or concerns from the resident's son, despite his statements that he reported multiple issues to both the former and new Administrators. These issues included concerns about medications, falls, a non-functioning bed and TV, and resident rights. The son reported that he did not receive any updates or progress regarding his complaints, and was particularly concerned about medications not being administered until the night before the resident's discharge. The resident involved had multiple diagnoses, including pulmonary hypertension, muscle wasting and atrophy, type 2 diabetes mellitus with peripheral angiopathy, atrial fibrillation, hypothyroidism, and chronic kidney disease. The resident was assessed as having intact mental cognition. Staff interviews revealed that grievances are typically assigned and resolved within a few days, and that maintenance issues are usually addressed promptly. However, the staff member responsible for social services was unable to explain why the resident's grievances were not documented in the report, stating that there were no reported grievances from the resident, despite the son's statements to the contrary.
Delay in Administration of Physician-Ordered Medications Upon Admission
Penalty
Summary
A newly admitted resident with multiple complex diagnoses, including pulmonary hypertension, muscle wasting, diabetes mellitus with peripheral angiopathy, atrial fibrillation, chronic kidney disease, osteoporosis, and hypothyroidism, did not receive physician-ordered medications for immediate care upon admission. The resident was assessed as having intact mental cognition and was admitted with weakness and a recent fall. The Advanced Registered Nurse Practitioner recommended continuation of current medications and fall risk precautions, and the pharmacist reviewed the medication regimen and made recommendations. However, there were no documented physician orders for several recommended medications, including gabapentin, carvedilol, calcitriol, allopurinol, and sodium bicarbonate, at the time of admission. Nursing progress notes indicated that medications were ordered by telephone on the day of admission, but these orders were not reflected in the resident's medical record or Medication Administration Record (MAR) until the tenth day of the resident's stay. During this period, there was a lack of documentation specifying which medications were unavailable or what new orders were implemented. The resident did not receive the recommended medications until the night before a resident-initiated discharge, despite facility staff stating that medications should be started as soon as possible after admission. Facility leadership was unable to provide an explanation for the delay in medication administration.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that physician orders were followed, resulting in a medication error rate of 32%, which is significantly higher than the acceptable threshold of 5%. During observations, interviews, and record reviews, ten medication errors were identified out of 31 opportunities, affecting four residents. The facility's policy on drug administration requires medications to be administered within one hour before or after their prescribed time, but this was not adhered to, leading to the high error rate. The errors were documented during a medication pass observation signed by the Consultant Pharmacist for a Licensed Practical Nurse (LPN).
Plan Of Correction
(1) Actions taken to correct the deficient practice: Resident #2 was evaluated on by the Unit Manager. There have been no ill effects noted from the medication errors. The physician and family were notified. The resident remains at the facility and is stable. Resident #3 was evaluated on by the Unit Manager for any side effects due to medication timing and administration errors and none observed. The physician and resident family were notified. The resident remains at the facility and is stable. Resident #5 was evaluated on by the Unit Manager for any side effects due to medication timing and administration errors and none observed. The physician and resident family were notified. The resident remains at the facility and is stable.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 32%. During medication administration observations, 10 errors were identified out of 31 opportunities, affecting multiple residents. The errors included improper timing of medication administration, with medications being given outside the one-hour window before or after the prescribed time. Staff members, including LPNs, were observed administering medications late, and some staff reported being overwhelmed with additional responsibilities such as skin care, answering call lights, and communicating with families and doctors. Specific instances included a resident receiving a chewable tablet separated from other medications due to its form, and another resident's medication being delayed due to low vital signs. Staff interviews revealed that management was aware of the delays, and some staff had attended medication administration in-services. Despite these efforts, the issue persisted, with staff struggling to manage their time effectively, leading to significant delays in medication administration.
Plan Of Correction
(1) Actions taken to correct the deficient practice: Resident #2 was evaluated on by the Unit Manager. There have been no ill effects noted from the medication errors. The physician and family were notified. The resident remains at the facility and is stable. Resident #3 was evaluated on by the Unit Manager for any side effects due to medication timing and administration errors and none observed. The physician and resident family were notified. The resident remains at the facility and is stable. Resident #5 was evaluated on by the Unit Manager for any side effects due to medication timing and administration errors and none observed. The physician and resident family were notified. The resident remains at the facility and is stable. Resident #6 was evaluated on by the Unit Manager for any side effects due to medication timing and administration errors and none observed. The physician and resident family were notified. The resident remains at the facility and is stable. Staff A received re-education on by ADON on administering medications as per physician orders and notification to supervisor and/or physician if medications may be administered outside of scheduled time frame. Staff B received re-education on by ADON on administering medications as per physician orders and notification to supervisor and/or physician if medications may be administered outside of scheduled time frame. Staff C received re-education on by ADON on administering medications as per physician orders and notification to supervisor and/or physician if medications may be administered outside of scheduled time frame. Staff E received re-education on monitoring the timeliness of medication administration and facility process to follow specific to timeliness of medication.
Medication Errors Persist Despite QAPI Efforts
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) Program failed to effectively address and correct identified quality deficiencies related to medication errors. During a revisit survey, surveyors observed 10 medication errors out of 31 opportunities, affecting four residents. This repeated deficient practice was previously cited during a recertification survey, indicating ongoing issues with medication administration. The Director of Nursing (DON) was informed of the medication administration errors, which were documented under F759, Free of Medication Errors. Despite the facility's plan of correction, which included re-education of licensed nursing staff on the medication administration process, the errors persisted. The facility's QAPI program did not ensure that the medication error rate was maintained below the acceptable threshold of 5%. The facility's survey history and plan of correction records were reviewed, revealing that the Licensed Practical Nurses (LPNs) involved had undergone orientation and medication pass observations. However, these measures were insufficient in preventing the recurrence of medication errors, highlighting a lack of effective implementation and monitoring within the QAPI program.
Plan Of Correction
(1) What corrective actions will be taken for those residents found to have been affected by the deficient practice: AD Hoc QAPI Meeting was held on with the Administrator, Medical Director, Director of Nursing and interdisciplinary team members. The meeting agenda included the components of Regulations: F759 Free of Medication Error rates 5% or more and F867 QAPI and the areas of concerns communicated on survey exit by the Agency for Health Care Administration. (2) How you will identify other residents having the potential to be affected by the same practice and what corrective actions will be taken: The Regional Vice President of Operations re-educated the Administrator on regarding the components of this regulation with emphasis on ensuring quality assurance monitoring of facility processes related Medication Administration. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: QAPI meeting was conducted on and by the Administrator. Participation included interdisciplinary team members as well as the Medical Director. Meeting agenda included the components of Regulations: F-759 Free of Medication Error Rates 5 Percent or more F-867 QAPI. Education was provided by the Administrator to QAPI team members on related to the elements of the Quality Assurance and Process Improvement program and to ensuring quality assurance monitoring of facility processes related to Medication Administration. (4) How the corrective actions will be monitored to ensure the practice will not recur: The facility Administrator/designee will conduct a quality review of QAPI to ensure quality assurance monitoring of medication administration to ensure ordered medications are being administered in a timely manner and as prescribed by the physician weekly x 4 weeks, and then every 2 weeks x 2 months then PRN as indicated. The findings of this quality monitoring will be reported to the QAPI monthly. Quality Monitoring schedule will be modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a deficiency in accommodating their needs and preferences. Resident #8, who was admitted with diagnoses including dizziness and heart disease, had a fall resulting in knee injuries. Despite an updated care plan intervention to keep the call light within reach, it was observed out of reach behind her bed during an interview. Resident #8 confirmed her inability to reach the call light, which was crucial for her to call for assistance due to her fall risk. Similarly, Resident #71, admitted with repeated falls and dementia, was observed with the call light out of reach on two separate occasions. Despite her severe cognitive impairment, she acknowledged the presence of the call light but was unable to reach it. Staff B, a Certified Nursing Assistant, confirmed the importance of keeping the call light accessible and responding promptly, especially for residents at risk of falls. The failure to ensure call lights were within reach for these residents highlights a deficiency in the facility's adherence to its policy and the residents' care plans.
Failure to Update Advanced Directives Status
Penalty
Summary
The facility failed to update the Advanced Directives status for a resident, leading to a deficiency. The resident, who was admitted with conditions including Multiple Sclerosis and Major Depressive Disorder, had a documented Do Not Resuscitate (DNR) order signed by both the physician and the resident. However, this DNR status was not reflected in the physician orders or the resident's Electronic Health Record (EHR) profile in Point Click Care (PCC). The care plan indicated the resident's desire for their Advanced Directives to be honored, but it did not specify the chosen code status. Additionally, there were inconsistencies in the documentation, with some notes indicating a Full Code status despite the resident's DNR order. Interviews with staff revealed a lack of clarity and consistency in the process of documenting and updating Advanced Directives. A Registered Nurse stated that if a DNR order was present, it should be uploaded to the PCC, but this was not done for the resident in question. The Social Worker mentioned that Advanced Directives should be initiated immediately upon admission and included in both the paper chart and EHR, with a physician's order in place within a week. However, this process was not followed, leading to the deficiency. The staff's understanding of the procedures for documenting Advanced Directives was inconsistent, contributing to the oversight.
Failure to Report Unwitnessed Fall with Injury
Penalty
Summary
The facility failed to report a resident's unwitnessed fall with an injury of unknown source, which is a violation of their policy and state law. The resident, who had a history of repeated falls and cognitive impairment, was found on the floor with significant injuries, including a large laceration on the forehead and skin tears on both legs. Despite the severity of the injuries and the resident's inability to explain the cause of the fall, the incident was not reported to the state agency as required. The Director of Nursing (DON) and the Administrator did not recognize the incident as reportable, assuming the fall was due to the resident's behavior of attempting to ambulate without assistance. The facility's investigation into the fall was incomplete, lacking documentation of corrective actions, follow-up, and a comprehensive fall risk assessment. Additionally, there was no evidence of neurologic checks or a fall log to track the resident's falls, which are essential components of the facility's policy. Interviews with staff revealed a lack of awareness and understanding of reporting requirements for falls with injuries of unknown sources. The Administrator believed that only incidents involving abuse or neglect needed to be reported, while the DON was unable to provide a complete investigation or corrective actions. This oversight highlights a significant deficiency in the facility's adherence to reporting protocols and the management of resident safety.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure that Resident #2 received treatment and care in accordance with physician orders for skin conditions. The resident, who was admitted with multiple diagnoses including Parkinson's Disease and cognitive impairment, had specific physician orders for wound care on her knees. These orders included cleansing and dressing changes on specified days. However, the facility's records and observations revealed that these orders were not consistently followed, as evidenced by undated and outdated dressings on the resident's knees. The March 2025 Treatment Administration Record (TAR) for Resident #2 lacked documentation of weekly skin checks and did not show evidence of dressing changes as per the physician's orders. Observations on multiple days showed that the dressings on the resident's knees were not changed according to the schedule, and there was no documentation of the resident refusing care. Interviews with the resident and staff confirmed the inconsistencies in care, with the resident expressing pain and difficulty in movement following a fall, and staff acknowledging the resident's confusion and occasional refusal of care. Further interviews with the Wound Care Nurse and Unit Manager confirmed that the dressing changes were not performed as ordered, and there was a lack of communication and documentation regarding the resident's care. The Wound Care Nurse admitted to performing a dressing change on a day not scheduled by the physician's orders, and the Unit Manager acknowledged the discrepancies in the TAR and the lack of progress notes regarding the resident's refusal of care. These failures in following physician orders and documenting care contributed to the deficiency identified by the surveyors.
Failure to Prevent Falls and Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for a resident with a history of falls and cognitive impairment. The resident, who was admitted with diagnoses including a history of traumatic fracture, Parkinson's Disease, and repeated falls, did not have a Fall Risk Assessment completed upon admission. Despite the facility's policy requiring such assessments within 24 hours of admission, this critical step was overlooked, leaving the resident without a tailored fall prevention plan. The resident experienced an unwitnessed fall resulting in significant injuries, including a laceration to the forehead and skin tears on both knees. The incident was not properly documented or investigated, as evidenced by the lack of a completed fall investigation report and missing documentation of neurologic checks after the resident returned from the hospital. The facility's Director of Nursing (DON) was unable to provide a comprehensive investigation or corrective actions, and there was no evidence of a fall log or follow-up as per the facility's policy. Interviews with staff revealed that the resident was often confused and attempted to ambulate without assistance, yet there was no effective intervention in place to address these behaviors. The resident's care plan was not updated in a timely manner, and the facility failed to report the fall with injury to the state, as required for such incidents. The lack of documentation and follow-up highlights a significant deficiency in the facility's fall prevention and response protocols.
Deficient Catheter Care and Infection Control Practices
Penalty
Summary
The facility failed to provide appropriate catheter care for Resident #96, who was observed with a urinary drainage bag hanging on the side of the bed without an anchoring device to secure the indwelling catheter. The resident, who has a history of neurogenic bladder and other medical conditions, was found to have an unsecured catheter, which was not in compliance with the facility's policy for catheter care. The resident had previously experienced a urinary tract infection, highlighting the importance of proper catheter management. During an observation of catheter care provided by Staff K, a CNA, several deficiencies were noted. The CNA did not perform hand hygiene after removing gloves and before putting on a new pair, which is against the facility's hand hygiene policy. Additionally, the CNA failed to provide privacy for the resident during the procedure, as the privacy curtain was not pulled, and the window blinds were not closed. The CNA also did not wear a gown, which is required under the facility's enhanced barrier precautions policy for high-contact resident care activities. The CNA's technique for cleaning the catheter was incorrect, as she wiped the catheter tubing from the drainage bag toward the resident's penis, rather than from the least contaminated to the most contaminated area. Furthermore, the catheter tubing was placed under the resident's leg without an anchor, which is not in accordance with the care plan's intervention to secure the catheter with a securement device. The Director of Nursing acknowledged these deficiencies during a side-by-side observation, confirming the improper placement and lack of anchoring for the Foley catheter.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to address significant weight loss in a timely manner for two residents, leading to deficiencies in nutritional care. Resident #14 experienced a 7.10% weight loss from January 7 to February 5, 2025, which was not addressed until February 13, 2025, when a nutritional note recommended adding Ensure and enhanced foods. However, documentation showed that the Ensure supplement was only recorded as given and accepted on 10 days out of the period from February 13 to March 8, 2025, without any percentage intake documented. Interviews with staff revealed that the documentation system only allowed for a yes or no response, and there was no option to record the percentage of supplement consumed. Resident #69 also experienced a significant weight loss of 18% from October 5 to December 5, 2024. A follow-up nutrition note on December 9, 2024, indicated a 17.2% weight loss trend, and Ensure was added twice a day for oral support. Despite this intervention, documentation from February 13 to March 8, 2025, showed that the Ensure supplement was only recorded as given and accepted on 23 out of 30 days, again without any percentage intake documented. Observations noted that Resident #69 was missing items from his breakfast tray, which were later provided by staff. Interviews with the Registered Dietitian and CNAs highlighted issues with the documentation process, as the system did not allow for detailed recording of supplement intake. The Registered Dietitian acknowledged that the response to significant weight loss should have been more prompt, and the CNAs confirmed that they could only document whether the supplement was taken, not the amount consumed. The facility's failure to adequately monitor and document nutritional intake contributed to the deficiencies identified by the surveyors.
Failure to Ensure Timely Physician Visits for a Resident
Penalty
Summary
The facility failed to ensure that the attending physician visits were performed in a timely manner for a resident with severe cognitive impairment. According to the facility's policy, residents should be seen by their physician at least monthly for the first 90 days following admission and at least once every 60 days thereafter. However, a review of the medical records for the resident revealed that there was no documentation from the attending physician, Staff H, indicating that he had performed a visit from December 6, 2024, to March 9, 2025. During an interview, Staff H stated that he sees residents initially every 30 days for the first 90 days and then alternates with the Nurse Practitioner (NP) every 60 days. He mentioned that the NP authors all notes and documents their collaboration on the plan of care, but he does not author any notes himself. The Director of Nursing acknowledged the lack of documentation indicating that the resident had been seen by the attending physician, confirming the deficiency in adhering to the facility's policy on physician visits.
Staffing Deficiency in Nursing and CNA Hours
Penalty
Summary
The facility failed to provide the minimum required nursing staff daily for 3 out of 28 days reviewed. According to the facility's policy, the minimum daily average hours for nursing staff should be 1.0 or greater, and for Certified Nursing Assistants (CNAs), it should be 2.0 or greater. However, the facility's Nurse Staffing Calculations from February 9, 2025, to March 8, 2025, showed that on February 15, 2025, the CNA daily average was 1.99, and on March 1, 2025, it was 1.97. Additionally, the nursing daily average was 0.98 hours on March 1, 2025, and 0.93 hours on March 8, 2025, both below the required minimum. Interviews with the Staffing Coordinator and the Director of Nursing confirmed that the staffing levels were below the required minimum during this period, particularly on weekends.
Incomplete Nurse Staffing Information Posting
Penalty
Summary
The facility failed to post complete and timely nurse staffing information for four consecutive days, as required by federal and state guidelines. Observations on multiple days revealed that the CMS Staff Postings at the nursing stations on both Unit 1 and Unit 2 only listed hours worked, without specifying the number of nursing staff or the name of the facility. This incomplete information was consistently observed on postings dated 02/28/25, 03/09/25, 03/11/25, and 03/12/25. Interviews with facility staff revealed a lack of clarity and consistency in the posting process. The Human Resources Director, who temporarily took over the posting duties, was unaware of the specific requirements and timing for posting the information. The regular Staffing Coordinator, who usually handles the postings, stated that she does not include the number of staff members on the postings, as this information is available on the assignment board at each nursing station. This practice led to the omission of required details on the CMS Staff Postings, contributing to the deficiency.
Non-compliance with PRN Psychotropic Medication Duration
Penalty
Summary
The facility failed to ensure that residents receiving PRN psychotropic medications were limited to 14 days or had documented rationale for extending the order beyond 14 days. This deficiency was identified for three residents. Resident #11 was admitted with anxiety and depression and was prescribed Alprazolam for 30 days without documentation justifying the extension beyond 14 days. Interviews with the Consultant Pharmacist and the Director of Nursing confirmed the lack of compliance with the 14-day limit. Resident #35, diagnosed with Generalized Anxiety Disorder, had a PRN order for Lorazepam without any documented rationale for extending the order beyond 14 days. The Director of Nursing acknowledged the absence of documentation to justify the extended use of the medication. The care plan for Resident #35 included interventions for mood changes but did not address the extended use of Lorazepam. Resident #15, with diagnoses of Generalized Anxiety Disorder and Major Depressive Disorder, had a PRN order for Alprazolam for 30 days. The Medication Administration Records for January, February, and March 2025 showed frequent administration of the medication, but there was no documentation of when the medication started or an end date. The Consultant Pharmacist and the Director of Nursing confirmed the lack of rationale for extending the PRN order beyond 14 days, indicating non-compliance with the facility's policy.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 13.33%. This deficiency was identified during medication administration observations involving two residents. Resident #85, who has Parkinson's Disease and moderate cognitive impairment, was administered medications significantly later than the prescribed time. The medications, including Carbidopa-Levodopa, Gabapentin, and Midodrine, were scheduled for 9:00 AM but were given at 12:00 PM. Additionally, the medications were improperly crushed and mixed with juice, contrary to administration guidelines. Interviews with staff revealed a lack of understanding regarding which medications should not be crushed, contributing to the error. Resident #11, diagnosed with Type 2 Diabetes Mellitus and moderate cognitive impairment, also experienced a medication administration error. The resident's Metformin was scheduled for 9:00 AM but was administered 1 hour and 50 minutes late. Interviews with staff indicated a misunderstanding of the facility's policy, which allows for a one-hour window before and after the scheduled time for medication administration. These errors highlight a failure in adhering to the facility's medication administration policies and procedures.
Medication Storage and Supervision Deficiencies
Penalty
Summary
The facility failed to ensure proper supervision and storage of medications for two residents, as well as secure medication carts. Resident #16, who has severe cognitive impairment and multiple diagnoses including dementia and depression, was observed with over-the-counter (OTC) medications such as Voltaren gel, saline nasal gel, and Refresh Tear eye drops left unattended on her bedside table and in her nightstand drawer. There was no physician order or care plan for self-administration of these medications, and staff confirmed that these items should not have been in the resident's room. Resident #307, who has no cognitive impairment but requires assistance with activities of daily living, was found with a tube of Voltaren gel on her bed. The resident stated she applied the gel before therapy, and the nurse was aware, but there was no physician order or care plan for self-administration. Staff removed the medications upon discovery and acknowledged the lack of proper authorization for the resident to have these medications at her bedside. Additionally, the facility failed to secure medication and treatment carts. An unlocked and unattended treatment cart was observed at the nursing station, and staff admitted it had not been used yet that day. Similarly, a medication cart was left unlocked and unattended by a nurse who had just arrived at the facility. A wound care cart containing prescription medications was also found unlocked and unattended, with the responsible nurse acknowledging she left it that way in a hurry.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety during multiple visits to the main kitchen. During the initial tour, several issues were identified, including a garbage bin with food debris and no lid in the food production area, and multiple sanitation buckets with no detectable sanitizing solution. Additionally, a square container with unidentified food and a jar of expired milk were found in the reach-in refrigerator, which was operating at an unsafe temperature of 58 degrees Fahrenheit. The walk-in refrigerator contained undated containers of Salisbury Steak and sandwiches past their use-by dates. The dishwasher machine was not functioning properly, with the wash cycle temperature below the required minimum. Personal water bottles were found in the food production area, and a cooking pot was noted with a dark sticky material. Egg salad plates were stored at unsafe temperatures, and the dietary aide confirmed they were prepared earlier that day. During a second visit, further deficiencies were observed, including an opened and unlabeled plastic bag of unidentified food in the walk-in freezer. These observations indicate a pattern of non-compliance with food safety standards, including improper food storage, inadequate sanitation practices, and equipment maintenance issues. The facility's failure to maintain proper food safety protocols poses a risk to the health and safety of its residents.
Inaccurate Documentation of Wound Care and Practitioner Roles
Penalty
Summary
The facility failed to maintain accurate clinical records for two residents, leading to deficiencies in care. For Resident #2, who was admitted with conditions including Parkinson's Disease and a history of falls, the facility did not accurately document wound care for a skin tear on the left knee. Despite physician orders for regular dressing changes, observations revealed that the dressing was not changed as documented in the Treatment Administration Record (TAR). The dressing was dated incorrectly, and there was no evidence that the resident refused treatment on several occasions, indicating a lack of accurate documentation and adherence to care protocols. For Resident #97, who was admitted with severe cognitive impairment and a history of traumatic subdural hemorrhage, the facility's records inaccurately listed a Nurse Practitioner as a Physician in the Medical Practitioner Notes. This misrepresentation occurred multiple times over several months, and there was no documentation of visits by the attending physician. The Director of Nursing acknowledged these inaccuracies, highlighting a failure in maintaining accurate and truthful medical records for the resident.
Infection Control Deficiencies in Equipment Disinfection and PPE Use
Penalty
Summary
The facility failed to adhere to CDC guidelines for Standard Precautions during the care of Resident #25. Staff Q, a Certified Nursing Assistant, was observed using the same set of gloves for multiple tasks, including opening the resident's door, handling trash, moving a meal table, and assisting with personal care, without changing gloves or performing hand hygiene. This action was contrary to the CDC's hand hygiene and PPE guidelines, which require changing gloves and washing hands between different tasks to prevent cross-contamination. In another instance, the facility did not properly disinfect vital signs equipment used for Residents #31 and #72. Staff O, a Registered Nurse, was observed using a blood pressure cuff and an oxygen saturation clip on Resident #31 without disinfecting them after prior use on Resident #72. Additionally, the equipment was returned to the storage basket without being cleaned, and there was no disinfectant available on the rolling vital signs machine. This failure to disinfect equipment between uses is a breach of CDC guidelines for the safe handling of potentially contaminated equipment. Resident #31, who had multiple health issues including Acute Respiratory Failure and a Multi Drug Resistant Klebsiella Urinary Tract Infection, was at risk due to the lack of proper equipment disinfection. Similarly, Resident #72, who was waiting for medication and had not yet had their blood pressure taken, was exposed to potential infection risks due to the improper handling of the blood pressure cuff. These observations highlight the facility's failure to maintain proper infection control practices, as confirmed by Staff R, an RN, who stated that staff were trained to perform hand hygiene and disinfect equipment, but these practices were not consistently followed.
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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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