Citations in Florida
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Florida.
Statistics for Florida (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in Florida
- Educated Administrator and DON on responsibility to implement the Excessive Heat Emergency Plan and monitoring/notification procedures (K - F0835 - FL)
- Educated Administrator and DON on job descriptions emphasizing accountability for maintaining safe temperatures and resident comfort (K - F0835 - FL)
- Reviewed affected regulations and emergency-plan implementation during QAPI meeting (K - F0835 - FL)
- Delivered facility-wide abuse/neglect training with post-test verification (K - F0600 - FL)
- Implemented policy barring staff from work until reeducated on Abuse and Neglect policies (K - F0600 - FL)
- Administered written competency test covering notification procedures for rooms at or above 81 °F (K - F0600 - FL)
- Provided staff instruction on cool-zone locations and consequences of failing to report high temperatures (K - F0600 - FL)
- Educated maintenance staff on maintaining facility temperatures between 71 °F and 81 °F (K - F0584 - FL)
- Established procedure to activate the emergency plan immediately when an air-conditioning unit fails (K - F0584 - FL)
- Educated clinical staff on abuse/neglect issues related to resident assessment and care when temperatures exceed 81 °F (K - F0584 - FL)
Failure to Maintain Safe Temperatures During Air Conditioning Outage
Penalty
Summary
Facility administration failed to utilize its resources effectively and efficiently to maintain a safe and comfortable temperature for residents when multiple central air conditioning units broke down in several halls and common areas. Despite being aware of ongoing issues with the air conditioning units, as documented in resident council meeting minutes from January through April, administration did not implement immediate and effective measures to address the excessive heat. Residents repeatedly raised concerns about uncomfortable temperatures, and the administration acknowledged the problems but only noted that the concerns were being addressed, without evidence of timely or sufficient action. On multiple occasions, temperatures in residents' rooms and common areas were measured between 81.3°F and 84.3°F, exceeding the recommended comfort range. Several residents reported ongoing discomfort, difficulty sleeping, and feeling overheated for weeks, with some stating that the issue had persisted for months. The facility's temperature monitoring logs did not include resident rooms and were only conducted twice a month in common areas, failing to capture the actual conditions experienced by residents. The Director of Nursing confirmed that interventions to mitigate heat exposure, such as providing ice, water, and monitoring vital signs, were not implemented until after temperatures had already reached excessive levels. Interviews with residents and staff further revealed that the excessive heat was a persistent problem, with residents expressing that their complaints were not adequately addressed. The administration's approach relied on hallway temperature checks to trigger room checks, which proved insufficient. The lack of timely and comprehensive action to ensure a safe and comfortable environment for all residents created a likelihood of serious harm or death due to prolonged exposure to excessive heat, resulting in the determination of Immediate Jeopardy.
Removal Plan
- Placed portable air conditioners and chillers throughout the facility to maintain temperatures between 71 and 81 degrees.
- Verified through resident interviews that the residents feel the temperature is now comfortable throughout the facility including in the resident rooms.
- Took temperatures throughout the facility at multiple times and verified they were within the range of 71 to 81 degrees.
- Facility will continue to maintain hourly temperature logs until all air conditioner units are repaired.
- Completed education with the Administrator and Director of Nursing (DON) by the President of Clinical Operations regarding their responsibility to implement the facility excessive heat emergency plan related to broken air conditioning units.
- Education included the monitoring process and notification procedure to the Chief Executive Officer/Chief Nursing Officer and to ensure residents are provided with a clean, comfortable environment.
- Chief Nursing Officer educated the Administrator and DON on their job descriptions, emphasizing responsibility to ensure proper temperatures and a safe, comfortable environment.
- Reviewed the agenda and staff sign-in page for the Quality Assurance and Performance Improvement (QAPI) meeting, which included a review of the affected regulations and implementation of the facility's Excessive Heat Emergency Plan.
Failure to Maintain Safe and Comfortable Temperatures Resulting in Resident Neglect
Penalty
Summary
The facility failed to protect residents from neglect by not taking immediate and appropriate actions to maintain safe and comfortable temperature levels when multiple central air conditioning units broke down in several halls and common areas. Despite the breakdown of the central air conditioning units in the 400, 500, and 700 halls, the facility did not implement its Emergency Preparedness Plan in a timely manner to ensure residents' comfort and minimize the risk of hyperthermia. Window air conditioning units were installed in some resident rooms, but there was no consistent monitoring of room temperatures to ensure they remained within a safe range. Residents repeatedly reported discomfort due to excessive heat, with room temperatures documented between 81.3°F and 84.3°F. Multiple residents complained of being excessively hot and uncomfortable for several days, with some describing difficulty sleeping and feeling as if they were overheating. Resident Council meeting minutes over several months also documented ongoing concerns about temperature regulation, indicating that the issue was persistent and not adequately addressed by facility leadership. Temperature monitoring logs provided by the facility only included common areas and did not document temperatures in individual resident rooms. The logs showed that temperatures were only checked twice a month, rather than more frequently, and did not reflect the elevated temperatures experienced by residents. The facility's own policies defined neglect as the failure to provide necessary goods and services to avoid physical harm or distress, yet there was no evidence that the facility consistently monitored or responded to unsafe room temperatures until after the deficiency was identified by surveyors.
Removal Plan
- Placed portable air conditioners and chillers throughout the facility to maintain temperatures between 71 and 81 degrees.
- Verified through resident interviews that the residents feel the temperature is now comfortable throughout the facility including in the resident rooms.
- Took temperatures throughout the facility and verified to be within the temperature range of between 71 and 81 degrees.
- Will continue to maintain hourly temperature logs until all air conditioner units are repaired.
- Provided facility-wide staff abuse/neglect education, verified through staff interview and record review of post-test results.
- Ensured no staff will be permitted to work until they are reeducated on Abuse and Neglect policies.
- Education included a written competency test to include who and when to notify when a resident room is at or above 81 degrees.
- Education included information on where the cool zones are located, and that failure to report is considered neglect.
Failure to Maintain Safe Room Temperatures During Air Conditioning Outages
Penalty
Summary
The facility failed to maintain a safe and comfortable air temperature range for residents when the central air conditioning units in multiple halls broke down. Specifically, the central air conditioning unit for the 500 hall failed on 4/28/25, and although window air conditioning units were installed in residents' rooms, the facility did not monitor the room temperatures to ensure they remained within a safe and comfortable range. Subsequently, on 5/19/25, the central air conditioning unit for the 400 hall also broke, and the facility did not implement immediate or appropriate actions to maintain safe temperatures in residents' rooms and common areas. On 5/20/25, temperatures in various resident rooms and common areas were measured between 81.3°F and 84.3°F, exceeding the recommended range and creating a likelihood of serious harm or death from prolonged heat exposure. Temperature monitoring logs from January through May 2025 showed that temperatures were only documented twice a month in common areas and hallways, not in individual resident rooms. The logs indicated temperature ranges up to 80°F, but did not capture the elevated temperatures that occurred in resident rooms during the air conditioning failures. Resident interviews revealed ongoing discomfort due to excessive heat, with multiple residents reporting difficulty sleeping, sweating, and feeling unwell over several days. Resident Council minutes from January through April 2025 documented repeated concerns about temperature regulation, with residents consistently reporting that temperatures were either too hot or too cold and that the issue was not being resolved. Staff interviews confirmed that the facility attempted to repair the air conditioning units and installed window units as a temporary measure, but did not implement a comprehensive safety plan or monitor room temperatures until after the elevated temperatures were identified by surveyors. The DON acknowledged that interventions to address the heat were not implemented until 5/20/25 at 3:30 p.m., after the high temperatures had already been present. The failure to monitor and control room temperatures, despite ongoing resident complaints and known equipment failures, resulted in the determination of Immediate Jeopardy due to the risk of heat-related complications for residents.
Removal Plan
- Placed portable air conditioners and chillers throughout the facility to maintain temperatures between 71 and 81 degrees.
- Verified through resident interviews that the residents feel the temperature is now comfortable throughout the facility including in the resident rooms.
- Temperatures were taken throughout the facility and verified to be within the temperature range of between 71 and 81 degrees.
- Maintenance staff were educated on maintaining the facility temperatures between 71 degrees and 81 degrees.
- Air conditioners will be maintained in working condition.
- If an air conditioner unit fails, maintenance staff along with administration will activate the emergency plan to maintain facility temperatures between 71 and 81 degrees.
- Clinical staff education on abuse/neglect related to assessment and care of residents when the temperatures are above 81 degrees, verified by posttest results and interview.
Failure to Prevent Resident-to-Resident Altercations Due to Inadequate Supervision
Penalty
Summary
The facility failed to implement adequate supervision and processes on the secured dementia unit to prevent multiple avoidable incidents of resident-to-resident physical altercations among cognitively impaired residents with aggressive behaviors. Over a period of several weeks, numerous residents with severe to moderate cognitive impairment and behavioral disturbances were involved in repeated physical altercations, including hitting, scratching, and grabbing, resulting in injuries such as skin tears, scratches, and emotional distress. These incidents occurred in various locations within the secured unit, including hallways, resident rooms, the dining room, and the activity room, often without staff present to intervene or prevent escalation. Care plans for residents with known aggressive behaviors and wandering tendencies were found to be insufficiently individualized and did not consistently include interventions to ensure adequate supervision or to protect other residents from harm. In several cases, residents with a history of aggression or wandering were not monitored closely enough, leading to altercations when they entered other residents' rooms or were in close proximity to others. Documentation revealed that staff were sometimes unaware of residents' whereabouts or did not witness the altercations, and in some cases, staff only became aware of incidents after hearing raised voices or residents calling for help. Behavioral monitoring and documentation of target behaviors for psychotropic medication use were also lacking or incomplete. The facility's failure to provide necessary structures and supervision resulted in physical injuries to several residents and created a likelihood of serious harm to others. The pattern of incidents demonstrated a lack of effective oversight and intervention for residents at high risk for aggressive behaviors, despite their known diagnoses of dementia, mood disorders, and behavioral disturbances. The deficiency was determined to be at the Immediate Jeopardy level due to the ongoing risk and actual harm experienced by residents on the secured dementia unit.
Removal Plan
- Educate the Administrator and Director of Nursing on ensuring that residents on the secured dementia unit are provided with adequate supervision to prevent incidents of resident-to-resident physical altercations and ensure resident safety.
- Educate staff on ensuring that residents on the secured dementia unit are provided with adequate supervision to prevent incidents of resident-to-resident physical altercations and ensure resident safety.
- Give specific examples of behavioral patterns that potentially lead to resident-to-resident altercations such as wandering patterns and behaviors, proximity of residents, verbal queues, and physical queues.
- Initiate enhanced monitoring and oversight by facility leadership over the secured unit to monitor patient care areas and resident rooms for resident behaviors that could lead to resident-to-resident altercations.
- Ensure that enhanced oversight of the secured unit is in place.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect residents' right to be free from abuse by not having effective processes in place to supervise cognitively impaired residents with known aggressive behaviors. Multiple incidents occurred in which residents with histories of aggression, wandering, or agitation were not adequately supervised, resulting in avoidable resident-to-resident altercations. These altercations led to physical injuries, including scratches and skin tears, among several residents. Specific events included residents hitting, scratching, or otherwise physically assaulting each other in various locations such as hallways, activity rooms, and dining areas. In several instances, residents with dementia or behavioral disturbances wandered unsupervised into other residents' rooms, leading to confrontations and injuries. Staff were observed not supervising residents at critical times, and altercations occurred without immediate staff intervention. The facility's monitoring program, which involved staff rounding every 15 minutes, was not sufficient to prevent these incidents. The facility's own records and staff interviews confirmed that incidents of resident-to-resident aggression continued to occur despite the implementation of monitoring programs. The Director of Nursing acknowledged the high frequency of such altercations, and the Administrator verified multiple incidents of physical abuse between residents. The lack of adequate supervision and ineffective monitoring processes directly resulted in physical harm to several residents and led to a determination of Immediate Jeopardy.
Removal Plan
- The Risk Consultant educated the Administrator and Director of Nursing on abuse, neglect, and exploitation as well as the reporting requirements to the Facility Risk Manager, Nursing Home Administrator, or direct supervisor as they relate to ensuring adequate supervision to ensure the safety of cognitively impaired residents on the secured dementia unit to prevent further incidents of resident-to-resident physical altercations and abuse.
- Administrator educated staff on abuse, neglect, and exploitation as well as the reporting requirements to the Facility Risk Manager, Nursing Home Administrator, or direct supervisor. 147 out of 147 staff members were educated.
- Administrator educated staff on abuse, neglect, and exploitation as they relate to ensuring adequate supervision to ensure the safety of cognitively impaired residents on the secured dementia unit to prevent further incidents of resident-to-resident physical altercations and abuse. 147 out of 147 staff members were trained.
- A Quality Assurance and Assessment meeting was held. Psychiatric services attended with the facility interdisciplinary team and reviewed high risk residents with behaviors. Medications and care planned interventions for behaviors were reviewed.
- Psychiatric service visits were increased for high-risk residents.
- Facility leadership along with the interdisciplinary team planned for enhanced oversight of the secured unit to monitor hallways and common areas for negative behaviors that could lead to a resident-to-resident altercation. Enhanced oversight was initiated.
- Two staff were assigned per shift to conduct enhanced oversight.
- The Administrator or designee is responsible for ensuring that enhanced oversight of the secured unit is in place.
- A qualified activity staff member was assigned to activities in the secured unit.
- A Quality Assurance meeting was conducted to review the effectiveness of the implemented interventions.
Failure to Follow Physician Orders and QAPI Process in Hypoglycemia Event
Penalty
Summary
The facility failed to utilize its Quality Assessment and Performance Improvement (QAPI) process to investigate, identify, and implement an effective performance improvement plan regarding the management of a resident's change in condition and adherence to physician orders. Specifically, a resident with Type 2 Diabetes Mellitus and a history of blood sugar monitoring experienced multiple episodes of hypoglycemia. On one occasion, an LPN administered glucose gel without a physician's order and did not notify the provider when the resident's blood sugar was 72. Subsequently, the resident became less responsive, and further blood sugar checks revealed dangerously low values. Despite a physician's order to administer Glucagon intramuscularly and send the resident to the emergency room if there was no positive response, the facility staff did not follow these instructions. When the resident's blood sugar dropped below 60 for a second time and the resident was unresponsive, the provider was not notified, Glucagon was not administered as ordered, and the resident was not sent to the emergency room. The resident's condition continued to deteriorate, with a blood sugar value of 32, and only then was emergency medical services contacted. The resident was transported to a hospital and did not survive. Interviews and record reviews revealed that the facility's QAPI process did not identify this event as a reportable incident or an area in need of improvement. The DON and nurse managers reviewed the case but failed to recognize deficiencies in care, documentation, and adherence to professional standards. The facility's policies and procedures for change in condition, physician notification, and following physician orders were not implemented, leading to a determination of Immediate Jeopardy.
Removal Plan
- The DON/designee completed a comprehensive audit of active residents in the facility with orders for blood sugar monitoring to ensure insulin administration was documented to identify concerns related to insulin administration in accordance with physician orders including administration of hypoglycemia interventions with documentation of repeat blood sugars.
- The DON/designee completed a review of residents who return to the hospital to ensure timeliness of RTH as it related to hypoglycemia was carried out.
- The DON/designee completed a comprehensive audit of active residents in the facility with change in condition to validate physician was notified and if blood sugar was completed as ordered.
- An Ad Hoc QA meeting was held for investigation of the concern and determination of the root cause analysis.
- Staff A, LPN, received 1:1 education on hypoglycemia/hyperglycemia protocol, and change in condition.
- The facility initiated a systemic change to include the notification to the DON/ADON when hypoglycemic interventions are initiated.
- Licensed nurses received education on blood sugar monitoring, documentation of results, follow up with physician, guideline for diabetes management, policy and procedure on change in condition, and notification of DON/ADON when hypoglycemic interventions initiated.
- VPCS reeducated the Clinical Management Team including the Administrator and Director of Nursing on the components of job descriptions and 5 elements of QAPI, root cause analysis, QAPI at a glance, and QAPI self-assessment tool.
- The Administrator/designees and Director of Nursing Services designee will ensure that the safety and well-being as it related to blood glucose monitoring and treatment is maintained by the continued participation, evaluation, and intervention through Dashboard, Risk reports, RTH Resident records and hour report review during clinical standup and stand down meeting, and maintaining QA/PI process.
- An Ad Hoc QAPI meeting was convened to review the components of ongoing PIP and review the findings of F867 QAPI/QAA.
Failure to Follow Hypoglycemia Protocol and Physician Orders Results in Immediate Jeopardy
Penalty
Summary
A facility failed to provide treatment and care according to professional standards of practice for a resident experiencing a change in condition related to hypoglycemia. The resident, who had a history of Type 2 Diabetes Mellitus and was under orders for regular blood glucose monitoring, experienced a series of low blood sugar readings. At one point, an LPN administered glucose gel without a physician's order and did not notify the provider of the resident's low blood sugar value. Subsequent blood sugar checks revealed further declines, and the resident became less responsive. Despite a physician's order to administer Glucagon intramuscularly if blood sugar dropped below 60 and to send the resident to the emergency room if there was no positive response, the facility did not follow these orders. When the resident's blood sugar dropped to 50 and then to 32, Glucagon was not administered as directed, the provider was not notified, and the resident was not sent to the emergency room as required. Documentation of blood sugar checks and interventions was incomplete, and the facility's policies for change in condition and physician notification were not followed. The resident was eventually transported to the hospital by emergency medical services but did not survive. Interviews with staff and review of records confirmed that physician orders were not followed, documentation was lacking, and professional standards for the management of hypoglycemia were not met. The failure to implement appropriate interventions and notify the physician placed all residents at risk and resulted in a determination of Immediate Jeopardy.
Removal Plan
- The DON/designee completed a comprehensive audit of active residents in the facility with orders for blood sugar monitoring to ensure insulin administration was documented to identify concerns related to insulin administration in accordance with physician orders including administration of hypoglycemia interventions with documentation of repeat blood sugars.
- The DON/designee completed a review of residents who return to the hospital to ensure timeliness of RTH (return to hospital) as it related to hypoglycemia was carried out.
- The DON/designee completed a comprehensive audit of active residents in the facility with change in condition to validate physician was notified and if blood sugar was completed as ordered.
- An Ad Hoc QA (Quality Assurance) meeting was held for investigation of the concern and determination of the root cause analysis.
- Staff A, LPN, received 1:1 education on hypoglycemia/hyperglycemia protocol, and change in condition.
- The facility initiated a systemic change to include the notification to the DON/ADON when hypoglycemic interventions are initiated.
- Licensed nurses received education on blood sugar monitoring, documentation of results, follow up with physician, guideline for diabetes management, policy and procedure on change in condition, and notification of DON/ADON (Assistant Director of Nursing) when hypoglycemic interventions initiated.
Latest Citations in Florida
A resident with dementia and other medical conditions was physically abused by a mental health technician, who roughly pulled the resident from a chair, resulting in a fall and subsequent injuries. The incident was witnessed by another resident and confirmed through interviews and review of facility records, revealing that the staff member's actions were rough and unnecessary, causing physical harm.
A resident with cognitive and mobility impairments was physically abused by a mental health technician, who roughly pulled the resident from a chair, resulting in a fall and subsequent injuries. The incident was not reported by the staff member, but was witnessed by another resident and later confirmed through interviews and video review. The facility's internal investigation verified the occurrence of physical abuse.
Surveyors found that the facility did not maintain required records for monthly and weekly maintenance and testing of its emergency generator, including battery testing, load testing, and visual inspections, as required by NFPA standards. The last documented load test was several months prior to the review, and the Maintenance Director confirmed the lack of documentation.
The facility did not ensure that staff were trained and available on all shifts to manually transfer power to the standby generator, which is necessary to maintain safe indoor temperatures during a power outage. The lack of training and absence of a designated individual to perform this task resulted in noncompliance with emergency environmental control requirements.
Three residents with wounds requiring dressing changes were found to have dressings that were not labeled with the required date, time, or staff initials, contrary to facility policy and professional standards. Staff interviews confirmed that labeling is expected after care, but observations showed this was not consistently done.
Surveyors found that food items brought in by visitors and family for residents were stored in nourishment refrigerators without proper labeling or dating. Staff confirmed the items belonged to residents, and facility policy requires labeling with resident names and use-by dates, but this was not followed.
A resident was unable to have food brought in by family reheated by staff after a prior incident where her food was burnt, leading the dietary manager to refuse further reheating. The facility had removed microwaves from each floor and maintained a policy that only dietary staff could reheat outside food, but staff were not permitted to do so, resulting in multiple resident complaints.
A resident with a history of schizophrenia and psychosis left the facility AMA without the responsible party being successfully notified, despite multiple attempts by the DON and facility policy requiring such notification. The resident's advocate later reported not being informed of the discharge, and documentation confirmed the notification process was incomplete.
A resident with disorganized schizophrenia and a colostomy left AMA without a safe discharge plan, valid destination, or notification to their advocate or representative. Facility staff did not involve social services in the discharge process, failed to promptly inform medical providers, and did not conduct a wellness check or notify authorities. The resident's location remained unknown at the time of the survey.
A resident with a history of schizophrenia and psychosis left the facility AMA without the required notification to their designated representative. Despite attempts by the DON to contact the responsible party by phone, no direct communication or documentation of notification occurred, and the resident's advocate later reported not being informed of the discharge.
Resident Physically Abused by Staff Member
Penalty
Summary
A deficiency occurred when a staff member physically abused a resident, violating the resident's right to be free from abuse. The incident involved a mental health technician who, according to multiple interviews and a now-overwritten video recording, engaged in rough physical handling of a resident on the facility's patio. The resident, who had diagnoses including dementia, psychosis, depression, and a history of falls, was moderately cognitively impaired but independent in activities of daily living. During the incident, the staff member pulled the resident out of a chair, and after a series of escalating interactions, the resident fell to the floor and was subsequently dragged or escorted to their room by the staff member. The resident sustained physical injuries, including bruises on the left knee and right forearm, and reported pain in the left knee. A physical assessment was performed, and the resident was found to be upset and yelling after the incident. The event was initially reported by another resident to the unit manager, who then assessed the resident and escalated the report to facility leadership. The incident was corroborated by interviews with the unit manager, DON, administrator, and social services director, all of whom reviewed the available evidence and confirmed the staff member's actions as physical abuse. The facility's own policies require staff to be able to identify and prevent abuse, but in this case, the staff member's actions were not reported by the perpetrator and only came to light through a third-party report. The incident was verified through internal investigation and interviews, and the staff member involved was found to have acted in a manner that was rough and unnecessary, resulting in physical harm to the resident.
Plan Of Correction
Plan of Correction - Complaint Investigations for #2025010806 and 2025010894 was conducted on July 28, 2025 - July 29, 2025. Citation: F600 (D/ N204-Class: III, Isolated) Corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. On 07/22/2025, after reporting the incident, Resident #1 had a head-to-toe assessment and pain assessment completed; Medical Doctor and Psychiatrist were notified; NP ordered X-rays and no fractures were identified. The facility reported the abuse reported to Adult Protective Services (DCF), police, and reported the event to AHCA on 07/22/2025, in accordance with the regulations. On 07/28/2025, Staff A (Mental Health Technician) was terminated from employment. On 7/23/2025, the Risk Manager of the facility conducted in-service education for all staff members on abuse; abuse prevention (handling difficult resident/residents with dementia or other challenging mental health diagnosis); and reporting of abuse. Identification of other residents having potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 7/24/2025, the ADON interviewed other residents to ensure that they had not been subject to abuse from Staff A or other members of facility staff. No additional complaints were identified. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: On 7/23/2025, the Risk Manager of the facility conducted in-service education for all staff members on abuse, abuse prevention (handling difficult resident/residents with dementia or other challenging mental health diagnosis), and reporting of abuse. The ADON, or designee, will conduct random interviews with current residents to identify any abuse/neglect/mistreatment. No less than 10 interviews will be completed weekly for 4 weeks. Any problems identified will be investigated, and appropriate actions will be taken as necessary. The Abuse Coordinator, or designee, will conduct random interviews with staff members on abuse, abuse prevention, and reporting requirements. No less than 10 interviews will be completed weekly for 4 weeks. Any problems identified will be investigated, and any appropriate actions will be implemented as necessary. All interviews will be submitted to the ADON, or designee, weekly for evaluation of trends and any educational needs. Ongoing frequency of interviews, after the initial 4 weeks, will be determined by the QAPI and QAA Committees. Corrective actions will be monitored to ensure the deficient practice will not recur. The findings from the interviews, along with any identified trends, educational needs, and any corrective actions taken as a result of the findings, will be submitted by the Administrator, or designee, to the QA and QAPI Committees monthly for 6 months, then quarterly for 4 quarters. Correction Date: 08/15/2025
Resident Physically Abused by Staff Member
Penalty
Summary
A deficiency occurred when a staff member physically abused a resident, violating the resident's right to be free from abuse as required by federal regulations. The incident involved a mental health technician who, according to multiple interviews and a review of video footage, roughly grabbed a resident by the arm and pulled them out of a chair on the patio. The resident, who had diagnoses including dementia, psychosis, depression, and mobility difficulties, subsequently fell to the floor and was then dragged or escorted to their room by the staff member. The resident sustained bruises and reported pain, though they refused pain medication. The incident was not reported by the staff member involved, and there were no other staff present at the time. The resident's care plan indicated a history of behavioral issues, such as spitting at staff and attempting to hit staff with a shoe, with interventions in place to maintain a safe distance during episodes of aggression. Despite these interventions, the staff member engaged physically with the resident in a manner that was described by facility leadership as rough and unnecessary. The event was witnessed by another resident, who reported it to the unit manager. The unit manager then assessed the resident and found physical injuries consistent with the reported incident. The facility's policy required all employees, volunteers, and contractors to be able to identify and prevent abuse. However, the staff member's actions, as corroborated by interviews with the unit manager, DON, administrator, and a DCF investigator, constituted physical abuse. The incident was verified through internal investigation and review of available video footage, which was later recorded over. The abuse was reported to the appropriate authorities, and the facility confirmed the occurrence of physical abuse following their investigation.
Plan Of Correction
Plan of Correction - Complaint Investigations for #2025010806 and 2025010894 was conducted on July 28, 2025 - July 29, 2025. Citation: F600 (D/N204-Class: III, Isolated) Corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. On 07/22/2025, after reporting the incident, Resident #1 had a head-to-toe assessment and pain assessment completed; Medical Doctor and Psychiatrist were notified; NP ordered X-rays and no fractures were identified. The facility reported the abuse reported to Adult Protective Services (DCF), police, and reported the event to AHCA on 07/22/2025, in accordance with the regulations. On 07/28/2025, Staff A (Mental Health Technician) was terminated from employment. On 7/23/2025, the Risk Manager of the facility conducted in-service education for all staff members on abuse; abuse prevention (handling difficult resident/residents with dementia or other challenging mental health diagnosis); and reporting of abuse. Identification of other residents having potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 7/24/2025, the ADON interviewed other residents to ensure that they had not been subject to abuse from Staff A or other members of facility staff. No additional complaints were identified. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: On 7/23/2025, the Risk Manager of the facility conducted in-service education for all staff members on abuse, abuse prevention (handling difficult resident/residents with dementia or other challenging mental health diagnosis), and reporting of abuse. The ADON, or designee, will conduct random interviews with current residents to identify any abuse/neglect/mistreatment. No less than 10 interviews will be completed weekly for 4 weeks. Any problems identified will be investigated and appropriate actions will be taken, as necessary. The Abuse Coordinator, or designee, will conduct random interviews with staff members on abuse, abuse prevention, and reporting requirements. No less than 10 interviews will be completed weekly for 4 weeks. Any problems identified will be investigated and any appropriate actions will be implemented, as necessary. All interviews will be submitted to the ADON, or designee, weekly for evaluation of trends and any educational needs. Ongoing frequency of interviews, after the initial 4 weeks, will be determined by the QAPI and QAA Committees. Corrective actions will be monitored to ensure the deficient practice will not recur. The findings from the interviews, along with any identified trends, educational needs, and any corrective actions taken as a result of the findings, will be submitted by the Administrator, or designee, to the QA and QAPI Committees monthly for 6 months, then quarterly for 4 quarters. Correction Date: 08/15/2025
Failure to Maintain and Test Emergency Generator per NFPA Standards
Penalty
Summary
The facility failed to provide evidence of proper maintenance and testing of its 135 KW diesel-powered generator in accordance with National Fire Protection Association (NFPA) standards. During a record review with the Maintenance Director, surveyors found that the facility did not have documentation for monthly specific gravity or conductance testing of the generator's maintenance-free battery, weekly voltage testing of the battery, monthly load testing of the life safety generator, or weekly visual inspections of the generator. The last documented monthly load test was dated several months prior to the review. These deficiencies were confirmed during an interview with the Maintenance Director, who acknowledged the lack of required records. The absence of these maintenance and testing records indicates that the facility did not adhere to the required schedules and procedures outlined in NFPA 99, NFPA 110, and NFPA 101 for ensuring the reliability of the essential electrical system, specifically the emergency generator and its components.
Failure to Ensure Trained Staff for Manual Emergency Power Transfer
Penalty
Summary
The facility failed to ensure that emergency power could be transferred to maintain safe indoor temperatures in the event of a loss of primary electrical power. During a review of the Comprehensive Emergency Management Plan (CEMP) and the generator/cooling plan, it was found that the facility only had a manual option to transfer power to the standby generator, which is responsible for supplying emergency power to the air conditioning system in designated cool zones. There was no evidence provided that an on-site and trained individual was available during all shifts to perform the manual transfer of power to the standby generator. This gap in staffing and training meant that, in the event of a power outage, there was no assurance that the generator could be activated promptly to maintain required temperatures for resident safety and comfort. Interviews with the Administrator and the Human Resource officer confirmed that staff had not been trained to perform the manual transfer of power. Additionally, it was stated that this training was not included as part of the emergency plan for new employee orientation. This lack of training and preparedness directly contributed to the facility's inability to meet the licensure requirement for emergency environmental control.
Failure to Label Dressings per Facility Policy
Penalty
Summary
The facility failed to follow its own resident care policies regarding the labeling of dressings, as required by their written procedures and professional standards of practice. Observations revealed that three residents had dressings or bandages that were not dated, timed, or initialed as specified in the facility's policy. Specifically, one resident was observed with an occlusive dressing on the left side that was not dated, another resident had three undated dressings on the right lower extremity, and a third resident had a dressing on the lower left lateral area with no date, time, or initials. These findings were confirmed through interviews with staff, who acknowledged that the expectation is to label dressings with the date and initials after care is provided. Record reviews showed that all three residents had medical conditions requiring wound care, such as wounds on the lower extremities and other chronic diagnoses. The facility's own policy and staff interviews confirmed that labeling dressings is a required step in the care process. However, the observed failure to consistently label dressings as per policy demonstrated noncompliance with both facility procedures and professional standards of practice.
Failure to Label and Date Resident Food in Nourishment Refrigerators
Penalty
Summary
Surveyors observed that the facility failed to store food under sanitary conditions in both nourishment refrigerators located on the resident units. Specifically, food items brought in by visitors and family members for residents were found in the refrigerators without proper labeling or dating. On one floor, there were multiple unlabeled grocery bags and plastic containers, some of which were dated but lacked resident names, while others had neither dates nor names. Similar issues were found in the refrigerator on another floor, where several plastic bags with food items were also unlabeled and undated. Interviews with facility staff confirmed that these food items belonged to residents and were stored in the pantry refrigerators. The Assistant Director of Nursing acknowledged that food should be labeled with the resident's name and a discard date, and that perishable items should be discarded after three days. Review of the facility's policy indicated that perishable foods must be stored in resealable containers, labeled with the resident's name, item, and use-by date, and that staff are responsible for discarding perishable foods on or before the use-by date. The observed practices did not align with these requirements.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Identified refrigerator on the second floor had 17 unlabeled grocery type bags with food items and three plastic containers in plastic bags with food items dated 05/29/2025 and had no names was discarded by the ADON 6/26/2025. Identified third-floor refrigerator with several unlabeled undated plastic bags with food items was discarded by the ADON 6/26/2025. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quality review to be completed by the DON/designee of the 2nd and 3rd floor refrigerators to ensure food items brought in from outside visitors/family are dated, labeled and stored appropriately under sanitary conditions 7/22/2025. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current licensed nurses re-educated by the DON/designee on the components of this regulation and to ensure food items brought in from outside visitors/family are dated, labeled and stored appropriately under sanitary conditions to be completed by 7/31/2025. 4) 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; DON/designee to conduct ongoing quality monitoring of the 2nd and 3rd floor refrigerators through visual observation to ensure food items brought in from outside visitors/family are dated, labeled, and stored appropriately under sanitary conditions twice weekly x requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Identified refrigerator on the second floor had 17 unlabeled grocery type bags with food items and three plastic containers in plastic bags with food items dated 05/29/2025 and had no names was discarded by the ADON 6/26/2025. Identified third-floor refrigerator with several unlabeled undated plastic bags with food items was discarded by the ADON 6/26/2025. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quality review to be completed by the DON/designee of the 2nd and 3rd floor refrigerators to ensure food items brought in from outside visitors/family are dated, labeled and stored appropriately under sanitary conditions 7/22/2025. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current licensed nurses re-educated by the DON/designee on the components of this regulation and to ensure food items brought in from outside visitors/family are dated, labeled and stored appropriately under sanitary conditions to be completed by 7/31/2025. 4) 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; DON/designee to conduct ongoing quality monitoring of the 2nd and 3rd floor refrigerators through visual observation to ensure food items brought in from outside visitors/family are dated, labeled, and stored appropriately under sanitary conditions twice weekly x four weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months then quarterly and PRN as indicated and modified based on findings.
Failure to Follow Policy for Reheating Outside Food
Penalty
Summary
The facility failed to follow its own policy regarding the reheating of food brought in by family or visitors for one resident. Observation revealed that the resident, who was seated in her wheelchair at the bedside, reported a disagreement with the dietary manager after her food was burnt when staff previously warmed it in the kitchen. As a result, the dietary manager refused to warm her food in the kitchen. The resident further explained that microwaves had been removed from each floor and that residents were required to have outside food warmed in the kitchen. Interview with the dietary manager confirmed that there were no microwaves available for residents and that staff were not permitted to reheat outside food, a longstanding policy despite multiple resident complaints. Review of the facility's policy indicated that only dietary staff are allowed to reheat outside food to prevent injury.
Plan Of Correction
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident Council Meeting to be held 7/2/2025 to review the policy r/t Food Brought in from Outside Visitors/Family. A copy of the Food Brought in from Outside Visitors/Family policy was placed in the admission packet by the ED 7/23/2025 and will be reviewed with new admissions, re-admissions and/or the resident representative as part of the admission process. Resident #13 grievance initiated and resolved 6/26/2025. Resident #13 educated on the policy r/t Food Brought in from Outside Visitors/Family by the ED 6/26/2025. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review of grievances received over the last 30 days from residents/visitors and/or staff with concerns related to not being able to have their food re-heated to be completed by the ED 7/31/2025. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Current facility staff re-educated by the ED/designee on the components of this regulation and the policy titled "Food Brought in from Outside Visitors/Family" to be completed by 7/31/2025. (4) 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 ED/designee to conduct ongoing quality monitoring through morning meeting r/t grievances regarding food not being able to be re-heated to ensure residents/visitors and staff have been provided education on the policy titled "Food Brought in from Outside Visitors/Family" 2 x weekly x 4 weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Failure to Notify Resident Representative of AMA Discharge
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's representative of a significant change in the resident's condition, specifically when the resident left the facility Against Medical Advice (AMA). The resident, who had diagnoses including Disorganized Schizophrenia and Psychosis, was admitted with a responsible party listed as an advocacy group. The resident was taking antipsychotic medications and had an active discharge plan for return to the community. On the day of the incident, the resident was found missing by staff, later located in another resident's room, and expressed a strong desire to leave the facility. The DON consulted with the physician, who advised allowing the resident to leave AMA. The resident refused to sign the AMA form and subsequently left the facility. Despite the facility's policy requiring notification of the resident's representative when a resident leaves AMA, the responsible party was not successfully notified. The DON reported making three or four phone calls and leaving a voicemail, but no response was received. The Social Services Director confirmed that the health care proxy should be notified about any incident and is the person designated to sign a resident out AMA. The resident's advocate stated during an interview that they were not notified of the resident's departure and expressed concern for the resident's safety and need for medication. Documentation reviewed included the resident's demographic sheet, admission/discharge/transfer list, MDS, physician's orders, care plan, and progress notes. The facility's policy on AMA discharge clearly outlined the requirement to notify the resident's representative and document the notification in the medical record. However, the lack of successful notification and documentation of the responsible party's awareness of the resident's AMA discharge constituted a failure to meet the regulatory requirement for notification of changes.
Plan Of Correction
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident #1 no longer resides in the facility. Resident left AMA 5/5/2025. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quality review over the last 30 days by the DON/designee to ensure the responsible party is notified of a resident's change in condition who leave AMA with documentation in the medical record to be completed by 7/31/2025. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current licensed nurses re-educated by the DON/designee on the components of this regulation and to ensure the responsible party is notified of a resident's change in condition who leave AMA with documentation in the medical record 7/31/2025. (4) 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 DON/designee to conduct ongoing quality monitoring through clinical meeting to ensure the responsible party is notified of a resident's change in condition who leave AMA with documentation in the medical record 2 x weekly x 4 weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings. The same monitoring process will be repeated: through clinical meeting to ensure the responsible party is notified of a resident's change in condition who leave AMA with documentation in the medical record 2 x weekly x 4 weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Inappropriate Discharge of Resident with Schizophrenia
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of disorganized schizophrenia and colostomy status left the facility against medical advice (AMA) without a safe and appropriate discharge plan. The resident, who was cognitively intact but had a history of delusional thinking and required ongoing antipsychotic medication, expressed a desire to leave and was presented with an AMA form, which he refused to sign. The facility did not obtain a valid address for the resident's next place of residence, nor did they inform the resident's advocate or representative about the AMA discharge. At the time of the survey, the resident's location was unknown. Facility staff failed to ensure that the resident was safely discharged to a location where ongoing clinical care could be provided. The Social Services Director was not involved in the discharge process and was not notified until after the resident had left. The resident's primary care physician and psychiatrist were not promptly informed of the resident's departure, and the facility did not conduct a wellness check or notify law enforcement, as no police or missing person reports were filed. The facility's own policy required notification of the resident's representative and documentation in the medical record, but these steps were not completed. Interviews with facility staff revealed confusion and lack of coordination regarding the resident's whereabouts and the discharge process. The Director of Nursing and Administrator acknowledged that the resident left without providing a destination and that attempts to contact the advocate were limited to leaving voicemails. The Social Services Director confirmed that she was not involved in the process and did not have a discharge location to perform a wellness check. The resident's advocate and medical providers expressed concern about the resident's safety and the lack of communication from the facility.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident #1 no longer resides in the facility. Resident isft AMA 5/5/2025. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quailty review over the last 30 days by the DON/designee to ensure a valid addresses is obtained upon admission/re-admission, to ensure residents are safely and appropriately discharged to a safe location where ongoing clinical care can be provided, and the responsible party is notified of a resident's change in condition who leave the facility AMA with documentation in the medical record to be completed by 7/31/2025. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current licensed nurses re-educated by the DON/designee on the components of this regulation and to ensure a valid addresses is obtained upon admission/re-admission, to ensure residents are safely and appropriately discharged to a safe location where ongoing clinical care can be provided, and the responsible party is notified of a resident's change in condition who leave the facility AMA with documentation in the medical record 7/31/2025. (4) 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 DON/designee to conduct ongoing quality monitoring through clinical meeting to ensure to ensure a valid addresses is obtained upon admission/re-admission to ensure residents are safely and appropriately discharged to a safe location where ongoing clinical care can be provided, and the responsible party is notified of a resident's change in condition who leave the facility AMA with documentation in the medical record 2 x weekly x 4 weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings. Current licensed nurses re-educated by the DON/designee on the components of this regulation and to ensure a valid addresses is obtained upon admission/re-admission, to ensure residents are safely and appropriately discharged to a safe location where ongoing clinical care can be provided, and the responsible party is notified of a resident's change in condition who leave the facility AMA with documentation in the medical record 7/31/2025. (4) 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 DON/designee to conduct ongoing quality monitoring through clinical meeting to ensure to ensure a valid addresses is obtained upon admission/re-admission to ensure residents are safely and appropriately discharged to a safe location where ongoing clinical care can be provided, and the responsible party is notified of a resident's change in condition who leave the facility AMA with documentation in the medical record 2 x weekly x 4 weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Failure to Notify Resident's Representative of Change in Condition During AMA Discharge
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in condition when the resident, who had a diagnosis of Disorganized Schizophrenia and Psychosis, left the facility Against Medical Advice (AMA). The resident was admitted with a responsible party listed as an advocacy group and was taking antipsychotic medications. Documentation showed that the resident had no cognitive impairment, as indicated by a Brief Interview of Mental Status (BIMS) score of 14 out of 15, and was actively involved in discharge planning for a return to the community. On the day of the incident, the resident insisted on leaving the facility, and the physician advised allowing the resident to leave AMA. The resident refused to sign the AMA form, and the responsible party was not present or notified in person. Interviews and record reviews revealed that the Director of Nursing attempted to contact the responsible party by phone several times and left voicemails, but no response was received. The Social Services Director confirmed that the health care proxy should be notified and is the person authorized to sign a resident out AMA, but this did not occur. Facility policy requires notification and documentation of the resident's representative when a resident leaves AMA, but this was not completed as required. The resident's advocate stated they were not informed of the resident's departure and expressed concern for the resident's safety and need for medication.
Plan Of Correction
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident #1 no longer resides in the facility. Resident left AMA 5/5/2025. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quality review over the last 30 days by the DON/designee to ensure the responsible party is notified of a resident's change in condition who leave AMA with documentation in the medical record to be completed by 7/31/2025. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current licensed nurses re-educated by the DON/designee on the components of this regulation and to ensure the responsible party is notified of a resident's change in condition who leave the facility AMA with documentation in the medical record 7/31/2025. (4) 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 DON/designee to conduct ongoing quality monitoring through clinical meeting to ensure the responsible party is notified of a resident's change in condition who leave AMA with documentation in the medical record 2 x weekly x 4 weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Explore Popular Searches
