Winkler Court
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Myers, Florida.
- Location
- 3250 Winkler Avenue Extension, Fort Myers, Florida 33916
- CMS Provider Number
- 105882
- Inspections on file
- 26
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Winkler Court during CMS and state inspections, most recent first.
A resident who was Medicaid pending had a spouse who paid funds toward the resident’s stay with the understanding that the amount would be refunded once Medicaid was approved. After the resident died and Medicaid coverage was established, the Business Office Manager confirmed that no balance was owed and that a refund was due, but the refund was processed through the corporate office and was not issued within the required timeframe. The spouse reported not receiving the $1,546.00 refund and stated she was repeatedly given excuses, while facility records showed the amount as a paid voucher, demonstrating a failure to timely refund resident funds as required by policy and regulation.
A nurse prepared and handed a cup containing multiple oral medications to a resident, then left the room without observing ingestion, contrary to facility policy requiring meds to be administered at the time of preparation and the resident to be observed until the dose is fully taken. Later observation found the full medication cup and an additional pill still on the bedside table, while the RN initially claimed the resident had swallowed all medications before ultimately acknowledging that she had not ensured ingestion.
Surveyors found multiple areas of disrepair and uncleanliness, including cracked walls, missing or broken closet doors, broken blinds, peeling cove base, and dirty dining room cabinets with food debris. Staff and residents reported that maintenance concerns had been known for months but were not addressed, and documentation showed that necessary repairs were not completed despite being reported. Residents expressed discomfort and dissatisfaction with the living environment, and staff confirmed ongoing issues with cleanliness and maintenance.
Several residents, including those with dementia and physical limitations, were served milk during in-room meal service without being provided glasses, cups, or straws, requiring them to drink directly from the carton. In some cases, milk cartons were not opened for residents unable to do so themselves, and one unresponsive resident was left with an uncovered tray and no assistance for an extended period. Staff acknowledged the lack of proper utensils and the need to improvise with straws.
The facility did not ensure that the required Florida DNR forms were signed by a physician in a timely manner for three residents who had chosen DNR status. In each case, although the residents or their representatives signed the forms, the physician's signature was missing, and the forms were not properly filed in the medical record as required.
Staff failed to consistently follow infection prevention protocols, including Enhanced Barrier Precautions, for several residents with wounds and indwelling devices. Gowns were not worn during high-contact care activities, PPE was not always accessible, and required audits were missed. Additionally, drainage bags were improperly positioned, and PICC line dressings were not changed as ordered, with documentation not matching observed evidence. These lapses in infection control practices were confirmed through staff interviews and direct observation.
A resident with multiple pressure injuries did not have an updated care plan reflecting new wounds, and staff failed to implement or communicate appropriate interventions such as repositioning and offloading. Staff interviews revealed inconsistent understanding of pressure injury protocols, and significant changes in wound status were not reported to clinical leadership or the physician.
A resident with multiple medical conditions and pressure wounds did not receive an accurate skin assessment upon admission, with subsequent weekly assessments revealing wounds that were not initially documented. Staff used a tablet app for wound assessment but reported inconsistencies in measurement and staging, and the care plan was not updated to reflect new findings. Leadership and medical providers were not consistently informed of wound changes, and staff lacked formal wound staging training.
A resident with a history of schizoaffective disorder experienced a return of serious mental illness after a reduction in antipsychotic medication, leading to escalating behavioral disturbances and a physical altercation. Despite these changes and a re-diagnosis of schizophrenia, the facility did not initiate a PASRR Level II referral, and the process for reassessment after the reemergence of mental illness was not addressed in facility policy.
A resident's request and physician's order for DNR status were not reflected in the care plan, which continued to indicate Full Code. Despite documentation and communication of the resident's wishes, nursing staff did not update the care plan accordingly.
A resident with dementia and cognitive impairment did not receive individualized activities as outlined in their care plan. Over multiple days, the resident was not offered activity materials, music, television, or staff-led engagement, and there was no documentation of activity participation or refusals. Staff interviews confirmed insufficient stimulation and a lack of direct engagement by the activities department.
A resident's spouse was allowed to administer medications without a physician order, assessment, or documentation, contrary to facility policy. Staff provided the spouse with the resident's medications and sometimes did not supervise administration, while nurses signed the MAR as if they had given the medications themselves. The resident had multiple diagnoses and required assistance, and the DON was unaware of the practice.
A resident with glaucoma and moderate cognitive impairment was left with broken glasses for months, despite expressing the need for repair or replacement. Staff were aware of the issue but did not follow facility policy to report or address the problem, and no follow-up was made for a scheduled eye care appointment.
A resident with multiple health conditions and high risk for skin breakdown developed new pressure wounds that were not identified at admission. Staff failed to consistently turn and reposition the resident, relying instead on offloading cushions, and did not provide adequate offloading for all affected areas. Wound assessments were not consistently performed or communicated, and significant changes in wound status were not reported to clinical leadership or the physician.
A resident with chronic kidney disease and other serious conditions did not consistently receive the ordered double portions of a therapeutic diet, especially during dialysis days. Staff failed to verify the contents of meals sent to the dialysis center, resulting in the resident experiencing hunger and not receiving adequate nutrition as prescribed.
Two residents experienced medication order discrepancies due to inadequate competency and documentation by nursing staff. One resident did not receive a prescribed daily hydrocortisone injection after hospitalization, as the facility administered only a one-time dose without proper documentation or notification. The facility's three-step medication review process was not documented. Another resident received an incorrect Gabapentin dosage due to entry errors and lack of physician notification. These incidents highlight a breakdown in medication reconciliation and adherence to facility policies.
Two residents experienced significant medication errors due to improper transcription and verification of hospital discharge orders. A resident with adrenal insufficiency did not receive prescribed daily hydrocortisone, leading to hospitalization. Another resident received incorrect Gabapentin dosage for several days. The facility's medication reconciliation process failed, with no proper documentation or physician notification.
Delayed Refund of Resident Funds After Medicaid Approval and Death
Penalty
Summary
The facility failed to ensure that all refunds due to a resident representative were issued within 30 days of discharge, as required by policy and regulation. The resident involved was admitted on an unspecified date and later expired at the facility. The resident’s spouse reported by telephone that the facility owed her a refund of $1,546.00 and that she had not yet received it, stating that the facility kept giving her excuses. The Business Office Manager (BOM) confirmed that the resident was Medicaid pending and that the resident representative had been responsible for paying $1,500.00, which was to be refunded once Medicaid was approved, and that the resident ultimately owed no money to the facility once Medicaid coverage began. The BOM stated that refunds are processed by the corporate office, not the facility, and attributed the delay to turnover in the corporate office, with each new staff member restarting the process. The BOM acknowledged that the refund, documented on an invoice as a voucher paid amount of $1,546.00 with payment status listed as “Paid,” was not issued within the required timeframe. This deficiency centers on the facility’s failure to comply with its own refund policy, which required refunds to be issued within the timeframe mandated by federal and/or state law, resulting in a delayed refund to the deceased resident’s spouse despite ongoing communication and confirmation that no balance was owed for the resident’s stay once Medicaid coverage was in place.
Medications Left Unattended at Bedside Without Ensuring Ingestion
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered in accordance with professional standards and the facility’s own medication administration policy. The policy required that medications be administered at the time they are prepared, by the same person who prepares them, and that residents be observed after administration to ensure the dose is completely ingested. During an interview and observation on 3/5/26 at 9:12 a.m., a medication cup containing seven pills and a separate large pink pill were observed on Resident #12’s bedside table, with no nurse present in the room. Resident #12 stated that the medications had been given to her, that she was supposed to take them, and that the nurse had handed them to her and then walked out. At 9:20 a.m., RN Staff A was observed at the medication cart and confirmed she had administered medications to Resident #12. When informed about the unattended pills, RN Staff A initially stated she had watched the resident take the whole cup and swallow the medications. At approximately 9:23 a.m., when RN Staff A and the surveyor returned to Resident #12’s room, the medication cup with the seven pills and the pink pill were still on the bedside table. RN Staff A questioned the resident about not taking the medications and then acknowledged she had given the medications and left the room without ensuring they were ingested, stating she knew this was wrong. These observations and interviews demonstrate that the nurse did not follow the facility’s policy or accepted professional standards for medication administration.
Failure to Maintain Safe, Clean, and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and home-like environment for residents, staff, and the public, as evidenced by multiple observations of disrepair and uncleanliness throughout the memory care unit and other areas. Surveyors observed cracked walls with exposed plaster, missing or broken closet doors, broken window blinds, peeling cove base, cracked and stained floors, missing bathroom tiles, and a sink separated from the wall. Additionally, foam was sprayed in a window corner, and a chair/bed rail was missing from a wall. The dining room cabinets were found to contain ground-in dirt, food debris, and trash, with the Director of Housekeeping acknowledging that cleaning had been missed and that such conditions could attract pests. The Administrator confirmed awareness of ongoing pest issues and agreed that the unit required updates. Further observations included a urinal stored on a bathroom handrail without resident identification, a bathroom door missing a doorknob, and a soiled privacy curtain with brown stains. Several rooms had broken or missing blinds and closet doors, with residents reporting that these issues had persisted for months. One resident expressed discomfort due to a bed that was too short, and staff confirmed that maintenance concerns had been reported but not addressed. Documentation showed that while quotes for supplies had been obtained, no orders had been placed for necessary repairs, and work orders were marked as completed despite the issues remaining unresolved. Interviews with staff, including LPNs, the ADON, the Regional Nurse Consultant, and the DON, confirmed awareness of the deficiencies, such as broken blinds and missing closet doors, but also revealed a lack of follow-through in addressing these concerns. Residents reported dissatisfaction with the state of their rooms, including missing closet doors that left their clothing exposed. The facility's own policy required work orders to be completed with priority, but evidence showed that repairs were not made in a timely manner, contributing to an environment that was not safe, clean, or comfortable for residents.
Failure to Provide Dignified Meal Service During In-Room Tray Administration
Penalty
Summary
During multiple observations of in-room meal tray service, five residents were not treated with respect and dignity as required. Residents with various diagnoses, including polyarthritis and dementia, were served milk without being provided glasses, cups, or straws, requiring them to drink directly from the carton. In several instances, milk cartons were not opened for residents who were unable to do so themselves, and one resident, who was unresponsive to verbal stimuli, was left with an uncovered tray and no assistance for 14 minutes. Staff interviews confirmed awareness of the issue, noting that the kitchen did not send cups and that staff had to find straws for residents to drink their milk.
Failure to Obtain Timely Physician Signature on Florida DNR Orders
Penalty
Summary
The facility failed to ensure that the physician signed the State of Florida Do Not Resuscitate (DNR) order in a timely manner for three residents who had chosen DNR status. In each case, although the residents or their representatives expressed their wishes and, in some instances, signed the state-specific yellow DNR form, the required physician signature was not obtained promptly. For one resident, a DNR order was initiated and documented in the medical chart, but the corresponding Florida DNR form was not signed by the physician. Staff interviews revealed that the care plan was not updated, and the state-specific form was not signed by either the resident or the physician until much later. For two other residents, the state-specific DNR forms were signed by the residents or their responsible parties, but the forms were not present in the medical chart as required and were later found unsigned in the physician's folder. The Director of Nursing confirmed that the Florida DNR form is necessary for resident transport and should be signed by both the resident and physician and placed in the chart. The facility's failure to obtain timely physician signatures on the DNR forms resulted in incomplete documentation of residents' advance directives.
Failure to Implement Effective Infection Prevention and Control Practices
Penalty
Summary
The facility failed to implement an effective Infection Prevention and Control Program (IPCP) for multiple residents, as evidenced by direct observations, interviews, and record reviews. Staff did not consistently follow Enhanced Barrier Precautions (EBP) for residents with wounds, indwelling devices, or those at risk for multidrug-resistant organisms (MDROs). For example, staff were observed providing care to residents on EBP without donning gowns, despite facility policy and posted signage requiring gown and glove use during high-contact care activities. In the Memory Care Unit, gowns were not available in designated storage areas, and daily PPE audits were not consistently performed. Staff interviews revealed gaps in knowledge and inconsistent adherence to EBP protocols, with some staff only using gowns for specific conditions like scabies, and others citing lack of PPE accessibility as a barrier to compliance. Additional deficiencies were identified in the management of indwelling catheter and vascular access devices. One resident with bilateral nephrostomy tubes was observed with drainage bags improperly positioned—one on the floor and another under the pillow—contrary to facility policy requiring drainage bags to be kept off the floor and below bladder level. Staff interviews confirmed awareness of the correct procedure, but the practice was not followed. Another resident with a PICC line had a dressing that had not been changed in accordance with the facility's policy and physician orders, with the dressing date indicating it had not been changed since hospital admission. Documentation in the Medication Administration Record (MAR) did not match physical evidence, and the DON was unable to provide proof of dressing changes as required. Further, staff were observed providing urinary catheter care and changing adult briefs for a resident with multiple indwelling devices and wounds without wearing gowns, despite clear signage and policy requirements. The RN Unit Manager did not intervene when observing this non-compliance. Staff interviews indicated that the omission was due to being in a hurry, and there was a lack of consistent understanding and enforcement of PPE protocols. These failures in infection control practices placed residents at risk for the transmission of MDROs and did not align with the facility's stated IPCP policies.
Failure to Update Care Plan and Implement Pressure Injury Interventions
Penalty
Summary
The facility failed to update or revise the comprehensive care plan for a resident with multiple pressure injuries, including a Stage 2 flank wound and a Stage 3 coccyx wound, which were not identified in the admission assessment. Weekly skin assessments later documented these wounds, but the care plan did not reflect goals or interventions for their management. There was also no documentation of communication regarding the new pressure injuries in the dialysis communication binder, and staff interviews revealed inconsistent understanding and implementation of repositioning and offloading protocols. The resident, who was cognitively impaired and dependent on staff for care, was observed without appropriate offloading devices and was not repositioned as needed, despite being at high risk for pressure injuries. Further observations and interviews indicated that staff, including CNAs and therapy personnel, believed that repositioning was unnecessary if an offloading cushion was used, and there was no scheduled turning program in place. The DON and Risk Manager confirmed the absence of a formal turn and reposition policy, and the wound care team had not reported significant changes in the resident's wound status, such as the presence of black tissue. The resident's physician and physician's assistant were not aware of the wound's progression, as they relied on nursing staff for updates, which were not provided. Photographic evidence was obtained to support these findings.
Failure to Ensure Accurate Assessment and Documentation of Pressure Wounds
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident with multiple complex medical conditions, including end stage renal disease, diabetes, cognitive impairment, and multiple pressure wounds. Upon admission, the resident's skin assessment did not document wounds on the coccyx or right flank, and the Minimum Data Set (MDS) did not reflect the presence or stage of these pressure injuries. Subsequent weekly skin assessments identified new wounds that were not present in the initial assessment, and the care plan was not updated to include these findings as of several days later. Observations revealed the resident was often found lying in bed with heels directly on the mattress and without appropriate offloading devices for pressure wound prevention. Interviews with nursing staff indicated that wound assessments were performed using a tablet application, but staff acknowledged that the accuracy of wound measurements and documentation could be compromised by user technique. There was inconsistency in wound staging and documentation, with discrepancies noted between staff descriptions and electronic records, including conflicting reports of wound characteristics such as the presence of slough or eschar. Further interviews with facility leadership and external vendors revealed a lack of formal wound staging training for staff, with education being provided by a dressing supply vendor who did not directly train staff on staging. The risk manager and DON were unaware of certain wound developments, and the resident's physician and physician assistant had not been informed of significant changes in the resident's wound status. The dressing supply vendor clarified that she only provides suggestions and does not assess or stage wounds, and had not observed staff performing wound assessments in several months.
Failure to Complete PASRR Level II Referral After Return of Serious Mental Illness
Penalty
Summary
The facility failed to complete a PASRR Level II referral for a resident who experienced a return of serious mental illness after admission. The resident, with a history of schizoaffective disorder, was initially determined not to require specialized services following a PASRR Level II assessment. After a psychiatric evaluation considered the disorder resolved, a gradual dose reduction of antipsychotic medication was initiated. Despite ongoing antipsychotic use and cognitive impairment, a significant change in status MDS assessment did not indicate the presence of serious mental illness. Over the following weeks, the resident exhibited escalating behavioral changes, including agitation, verbal outbursts, territorial guarding, and physical aggression, culminating in an incident where the resident physically assaulted a roommate. Subsequent psychiatric evaluation confirmed the return of psychotic symptoms and resulted in a re-diagnosis of schizoaffective disorder. The resident's medication regimen was adjusted, and the diagnosis list was updated to reflect active schizophrenia. Observations documented ongoing behavioral disturbances, and staff interviews confirmed increased aggression and territoriality, particularly after the medication dose reduction. The facility's policy did not address the process for PASRR assessment following the reemergence of serious mental illness post-admission, and there was no documentation of a PASRR Level II referral being initiated or completed after the resident's condition changed.
Failure to Update Care Plan to Reflect Resident's DNR Status
Penalty
Summary
The facility failed to develop a comprehensive care plan that accurately reflected a resident's choice regarding code status. Although a physician's order and nursing progress note documented the resident's request for Do Not Resuscitate (DNR) status, the care plan continued to indicate Full Code status, which would require initiation of CPR. Interviews with the resident confirmed she had communicated her desire for DNR status to the facility. Both the RN and Unit Manager acknowledged that the care plan was not revised to reflect the resident's wishes, and the Director of Nursing confirmed that the care plan should have been updated at the time of the resident's request. This deficiency was identified for one resident whose advanced directives were not accurately documented in the care plan, despite clear communication and documentation of the resident's wishes and physician's orders.
Failure to Provide Individualized Activities for Resident with Dementia
Penalty
Summary
The facility failed to provide activities designed to meet the interests and well-being of a resident with dementia and cognitive impairment. The resident's care plan included goals for daily participation in activities of choice, with interventions such as encouraging engagement in general activities and providing in-room activities if preferred. However, over several days of observation, the resident was not offered any activity materials, music, television, or staff-led activities, except for a Daily Chronicle paper at the bedside. There was no documentation of activity refusals or participation in any activities for the past 30 days. Interviews with staff revealed that the resident expressed interest in watching TV but did not have access to a TV remote, and staff acknowledged that the resident was not receiving enough stimulation. The Director of Activities had not personally engaged the resident, and activity documentation was lacking. The Social Services Director indicated that interventions for loneliness or withdrawal would involve family and interdisciplinary team input, but there was no evidence of such actions for this resident. The lack of individualized activities and engagement was confirmed by multiple staff members and through record review.
Failure to Ensure Proper Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders and facility policy for one resident. Staff allowed the resident's spouse to administer medications without a physician order, assessment of the spouse's capability, or documentation in the care plan. The spouse reported that he was given the resident's medications by staff and administered them without supervision, and there was no evidence that the physician was notified or that the spouse was properly trained. Staff interviews confirmed that the resident would only take medications from her husband, and that nurses provided the medications to him, sometimes without remaining present to ensure administration. The Medication Administration Record was signed by nurses as if they had administered the medications themselves. The resident involved had diagnoses including protein calorie malnutrition, convulsions, muscle weakness, and required assistance with personal care. The spouse reported concerns about medication administration practices, including medications being given on an empty stomach, a double dose of Keppra, and a missing dose of Eliquis. The Director of Nursing was unaware that the spouse was administering medications and confirmed there was no assessment or documentation to support this practice. Facility policy required medications to be administered by authorized personnel and in accordance with prescriber orders, which was not followed in this case.
Failure to Assist Resident with Vision Services and Glasses Repair
Penalty
Summary
The facility failed to assist a resident in obtaining necessary vision services and in ensuring that the resident's glasses were in good repair. The resident, who had diagnoses including type 2 diabetes mellitus, hemiplegia, and glaucoma, was observed multiple times wearing broken bifocal glasses missing the left arm of the frame. Despite the resident expressing a desire for new or repaired glasses, no action was taken to address the issue. Staff interviews revealed that the resident's glasses had been broken for months, and although the care plan instructed staff to report any damage to glasses, neither the Director of Nursing nor the Social Service Director were aware of the problem. The process for addressing vision concerns was not followed, as staff failed to notify the appropriate personnel or initiate the required documentation for repair or replacement. Additionally, the facility did not follow up on a physician's order for an eye care visit scheduled six months after the last consultation, and there was no documentation of any subsequent appointment or evaluation. The resident's cognitive skills were noted as moderately impaired, further emphasizing the need for staff assistance in managing vision care. The facility's policy required prompt referrals and assistance with appointments for vision and hearing services, but these procedures were not implemented for this resident, resulting in an unresolved deficiency.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
A resident with multiple comorbidities, including end stage renal disease, diabetes, cognitive impairment, and immobility, was admitted to the facility with a high risk for skin breakdown and existing pressure wounds. Initial assessments did not identify wounds on the coccyx or right flank, and the admission MDS did not document the presence of stage 3 or unstageable pressure injuries, nor did it include interventions such as pressure-reducing devices, a turning/repositioning program, or nutrition/hydration measures. However, within days, new wounds were identified, including a stage 2 wound on the right rear flank and a stage 3 wound on the coccyx, which were not present or documented at admission. Observations and interviews revealed that the resident was not consistently turned or repositioned, especially while in bed or in a wheelchair, despite being at high risk for pressure injuries. Staff, including CNAs and therapy personnel, expressed a belief that offloading cushions alone were sufficient and that repositioning was not necessary when such devices were used. There was no scheduled turning or repositioning program in place, and the care plan only included general interventions such as turning and repositioning as needed. The resident was observed sitting on an obstructed offloading cushion and without offloading support for the right flank wound, and staff confirmed that no specific offloading or repositioning was provided for that area. Further, wound assessments were inconsistent and not promptly communicated to clinical leadership or the physician. The presence of black tissue in the right flank wound, indicating an unstageable wound, was not documented as a significant change in condition, and neither the physician nor the physician's assistant were made aware of this development. The wound team had not seen the wound for at least a week, and there was a lack of clear communication and documentation regarding the resident's wound status and necessary interventions.
Failure to Provide Ordered Therapeutic Diet for Dialysis Resident
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including chronic kidney disease, diabetes, anemia, heart failure, chronic ulcers, and kidney failure, was not consistently provided with the ordered therapeutic diet. The resident, who is cognitively intact and attends dialysis three times per week, reported feeling extremely hungry after returning from dialysis. Staff interviews and record reviews revealed that although the resident was supposed to receive a chronic kidney disease diet with extra portions, there was a lack of clarity and follow-through regarding the contents and adequacy of the meals provided, particularly the lunch sent to the dialysis center. Observations showed that the resident's lunchbox sometimes contained only a sandwich, crackers, and an empty water bottle, which did not meet the ordered double portions. The kitchen manager admitted to not verifying the contents of the lunchboxes beyond checking their weight and did not open them to ensure accuracy. Both the dietician and kitchen manager were unaware of the resident's complaints of hunger and only realized after review that the resident should have been receiving additional food items. This failure to provide the prescribed therapeutic diet led to the resident experiencing hunger and not having his nutritional needs met as ordered.
Medication Order Discrepancies Due to Inadequate Competency and Documentation
Penalty
Summary
The facility failed to ensure that licensed nurses had the necessary competencies and skill sets to provide appropriate nursing and related services, as evidenced by medication order discrepancies for two residents. For the first resident, after returning from hospitalization, the discharge orders included a daily intravenous hydrocortisone injection. However, the facility administered only a one-time intramuscular dose and discontinued the daily order without proper documentation or notification to the Advanced Registered Nurse Practitioner (ARNP) or physician. The ARNP was unaware of the hospital's daily steroid order and did not discontinue it, indicating a lack of communication and documentation. The Director of Nursing (DON) described a three-step medication review process involving initial review, a 24-hour chart check, and a morning meeting review. However, for the first resident, the DON could not provide documentation that these steps were completed, as the 24-hour chart check and admission checklist were missing, and the Medication Review Report was unsigned by the provider. This lack of documentation and verification contributed to the oversight in medication administration. For the second resident, the hospital discharge orders included a specific dosage of Gabapentin, but the facility entered and administered an incorrect dosage for several days. The error was eventually corrected, but there was no documentation of physician notification or discussion regarding the dosage change. The DON acknowledged that the error was due to incorrect entry by the RN Unit Manager and a failure to identify the mistake during the second check by the weekend supervisor. This incident highlights a breakdown in the medication reconciliation process and a failure to adhere to the facility's policy on event reporting and physician notification.
Medication Errors in Resident Care
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the improper administration of medications for two residents. Resident #1, who had a history of adrenal insufficiency, was discharged from the hospital with an order for daily intravenous hydrocortisone. However, upon readmission to the facility, the order was incorrectly transcribed as a one-time intramuscular injection, and the daily administration was discontinued without proper documentation or physician notification. This error led to a significant decline in Resident #1's condition, resulting in hospitalization for adrenal insufficiency due to corticosteroid withdrawal. Resident #2 was admitted with a hospital order for Gabapentin 200 mg twice daily, but the facility entered the order incorrectly as 100 mg twice daily. This error persisted for several days until it was corrected, but there was no documentation of physician notification or discussion regarding the dosage change. The Director of Nursing (DON) was unaware of the discrepancies until the survey, indicating a lapse in the facility's medication reconciliation and verification processes. The facility's policies for physician orders and event reporting were not followed, as evidenced by the lack of documentation and failure to complete the required checks and verifications. The DON and staff involved did not ensure that the medication orders were accurately entered and reviewed, leading to significant medication errors for both residents. The facility's process for medication reconciliation, particularly for residents returning from hospital stays, was inadequate, resulting in these deficiencies.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
