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)
Latest Citations in Florida
Surveyors found that the facility's designated resident smoking area in the courtyard lacked a required self-closing metal butt can for cigarette disposal, as mandated by NFPA 101. The Maintenance Director confirmed the absence of this fire safety equipment during the inspection.
A resident with right-sided hemiplegia and aphasia, dependent on staff for ADLs, did not receive ordered passive range of motion (PROM) exercises or brace application as documented in the care plan and physician's orders. Staff interviews revealed a lack of awareness and implementation of these interventions, and review of the Treatment Administration Record showed no documentation of the required care, resulting in a deficiency for failure to maintain or improve range of motion.
Surveyors identified expired medications in two medication carts during a review, including an expired bottle and a gel for a resident that was past its use date. The facility's policy requires checking expiration dates before administration, but the DON confirmed expired medications should not be present and noted that cart checks occur weekly but need better follow-through.
A medication error rate of 8% was identified when an LPN crushed and administered two extended-release medications to a resident, despite both being contraindicated for crushing. The facility's policies and physician orders required staff to avoid altering medications when contraindicated, and both the consultant pharmacist and DON confirmed the error. This deficiency was observed during a survey and was based on direct observation, record review, and staff interviews.
The facility did not ensure RN coverage for at least 8 consecutive hours on two reviewed days, as required by federal regulations. Staffing records and time sheets showed that on these days, RN hours fell short, and staff interviews confirmed no other RN was present to meet the requirement.
A resident with diabetes and on both long-acting and short-acting insulin had physician orders requiring blood glucose checks and insulin administration at 11:30 AM. On days when the resident left for dialysis, the 11:30 AM insulin dose and required monitoring were missed, as documented in the MAR. The DON was unaware if the physician knew about the missed doses, and the physician believed the orders should have been clarified to account for the resident's dialysis schedule. Staff confirmed that missed doses occurred and that order clarification had not taken place.
A resident with significant physical and cognitive impairments did not receive prescribed passive range of motion exercises or brace application as ordered in their care plan and physician's orders. Staff were unaware or did not implement the required interventions, and documentation confirming these treatments was absent.
Surveyors found that a fire-rated door leading to a hazardous dry storage room, protected by a one-hour fire barrier and equipped with a self-closing device, was held open by a bungee cord and obstructed by a storage rack, preventing it from self-closing and latching as required by NFPA 101. The Administrator confirmed the door should remain closed, and the deficiency was cited based on these observations.
Three gas-fed appliances on casters under the commercial cooking hood were found with restraint tethers attached but not secured to the wall attachments, as confirmed by the DOM during inspection. This failure to properly limit appliance movement resulted in non-compliance with NFPA 101, NFPA 96, and NFPA 54 standards.
Two residents received controlled substances with documentation showing more doses administered than prescribed, and medication logs were found to be illegible and inconsistent. An LPN was associated with multiple discrepancies, including altered dates and unclear signatures, leading to inaccurate records of medication administration.
Noncompliance with Smoking Area Fire Safety Requirements
Penalty
Summary
During a fire life safety survey, it was observed that the facility failed to comply with National Fire Protection Association (NFPA) 101 smoking regulations. Specifically, the established smoking area in the courtyard, which was the only designated area for residents to smoke, did not have a self-closing metal butt can as required by the standard. This deficiency was identified during a facility tour conducted between 1:00 p.m. and 5:00 p.m. with the Maintenance Director present. The surveyor noted that the absence of a self-closing metal container for cigarette disposal in the smoking area was a direct violation of NFPA 101 (2012 and 2021 Editions) section 19.7.4(6). The regulation mandates that metal containers with self-closing cover devices, into which ashtrays can be emptied, must be readily available in all areas where smoking is permitted. The report also clarified that smoking tower disposal receptacles do not meet the requirement for ashtrays or self-closing metal containers. The Maintenance Director acknowledged the findings during the interview that was conducted concurrently with the observations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency were provided in the report. The deficiency was based solely on the lack of required fire safety equipment in the designated smoking area.
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 in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On , an order was placed for two new red cigarette butt cans by the Director of Maintenance. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On , the Maintenance Director, and Administrator will conduct an audit on facility's red cigarette butt cans to identify potential issues with the cans and to ensure they are opening and closing fully. Any issues identified were corrected. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On, facility staff were educated on the components of K0741 to ensure a safe, comfortable, and compliant smokers' area with emphasis on reporting equipment concerns through the electronic work order system for follow-up by the Assistant Director of Nursing. Newly hired staff will be educated by the Assistant Director of Nursing/Designee on the components of K0741 during orientation with an emphasis on ensuring a safe smoking area environment by reporting physical environment concerns through the electronic work order system as part of the systematic change. 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 Maintenance Director/Designee will conduct audits of the physical environment of the smoking area 1 time/week for 4 weeks, then monthly for 2 months to ensure that no homelike environment concerns exist and compliance with Federal Regulation K0741. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines that substantial compliance has been met. The cans and to ensure they are opening and closing fully. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On, facility staff were educated on the components of K0741 to ensure a safe, comfortable, and compliant smokers' area with emphasis on reporting equipment concerns through the electronic work order system for follow-up by the Assistant Director of Nursing. Newly hired staff will be educated by the Assistant Director of Nursing/Designee on the components of K0741 during orientation with an emphasis on ensuring a safe smoking area environment by reporting physical environment concerns through the electronic work order system as part of the systematic change. (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 Maintenance Director/Designee will conduct audits of the physical environment of the smoking area 1 time/week for 4 weeks, then monthly for 2 months to ensure that no homelike environment concerns exist and compliance with Federal Regulation K0741. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines that substantial compliance has been met. On, facility staff were educated on the components of K0741 to ensure a safe, comfortable, and compliant smokers' area with emphasis on reporting equipment concerns through the electronic work order system for follow-up by the Assistant Director of Nursing. Newly hired staff will be educated by the Assistant Director of Nursing/Designee on the components of K0741 during orientation with an emphasis on ensuring a safe smoking area environment by reporting physical environment concerns through the electronic work order system as part of the systematic change. (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 Maintenance Director/Designee will conduct audits of the physical environment of the smoking area 1 time/week for 4 weeks, then monthly for 2 months to ensure that no homelike environment concerns exist and compliance with Federal Regulation K0741. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines that substantial compliance has been met.
Failure to Provide and Document Range of Motion Interventions
Penalty
Summary
A deficiency was identified when the facility failed to provide appropriate treatment and services to prevent a decline in range of motion for a resident with limited mobility. The resident, who had a history of right-sided hemiplegia and aphasia following a cerebrovascular event, was dependent on staff for activities of daily living and had documented functional limitations in the upper and lower extremities on one side. The care plan and physician's orders specified that the resident should receive passive range of motion (PROM) exercises and application of a brace to the right side, with specific instructions for timing and monitoring. Despite these documented interventions, observations and record reviews revealed that the resident did not receive the ordered PROM or brace application. The Minimum Data Set (MDS) assessment indicated that the resident had not received passive or active range of motion or brace assistance for at least 15 minutes in the previous seven days. Interviews with staff members, including CNAs and LPNs, showed a lack of awareness or implementation of the prescribed interventions, with one CNA stating that the resident did not have anything in place for the right side at the time of observation, and an LPN not being aware of any device for the resident's right side. Further review of the Treatment Administration Record (TAR) confirmed the absence of documentation that PROM or brace application had been performed as ordered. The Director of Nursing verified the lack of documentation and confirmed that the resident had an active order for these interventions. The failure to provide and document the required care and services led to the deficiency under the federal regulation for maintaining or improving range of motion and mobility.
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 it is required. F688 Increase/Prevent Decrease in ROM/Mobility (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On , Resident # 31 was assessed by a licensed nurse. No concerns were noted related to the alleged deficient practice. On the order was clarified with MD to indicate donning and doffing of , as well as performing PROM. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken, On Audit was completed by Director of Nursing/designee on residents who had orders for /braces to ensure order indicated donning and doffing equipment. Any issues identified were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By Current Nurses and staff will be educated on the components of F688 with an emphasis on documenting the donning and doffing of a /brace and following the comprehensive resident centered care plan and Prevention of decrease in ROM/Mobility by the DON/Designee. Newly hired licensed nurses/ . Staff will be educated on the components of F688 with an emphasis on documenting the donning and doffing of a /brace and following the comprehensive resident centered care plan and prevention of decrease in ROM/Mobility by the Director of Nursing/Designee at orientation as a part of the systematic changes. (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: Director of Nursing/Designee to conduct audits of 5 residents with physician orders for a /brace 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that the physician order includes documentation of donning and doffing /brace. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Expired Medications Found in Medication Carts
Penalty
Summary
Surveyors found that the facility failed to remove expired medications from two of four medication carts reviewed, specifically the "Colonial 1" and "Heritage" carts. During observations, one bottle with an expired date was found on the Colonial 1 cart, and a bottle of gel 0.5 mg/mL for a resident was found on the Heritage cart with packaging that specified it should not be used after a certain date. Photographic evidence was obtained for both findings. The facility's policy requires that the expiration or beyond-use date on medication labels be checked prior to administration. In an interview, the DON acknowledged that expired medications should not be present in the medication carts and stated that medication carts are checked on Sundays, but indicated there was a need to improve follow-through with these checks.
Plan Of Correction
F755-Pharmacy Services/Procedures/Pharmacist/Records (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On the expired and gel were removed from the medication carts. Audit was conducted of remaining medication carts with no other concerns were noted related to the alleged deficient practice. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; An audit was completed by the Director of Nursing/designee on all medication carts and medication rooms to ensure there were no outdated or expired medications. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By current licensed nurses will be educated on the components of F755 with an emphasis on monitoring medications for expiration dates and appropriate medication storage by the DON/Designee. Newly hired licensed nurses will be educated on the components of F755 with an emphasis on monitoring medications for expiration dates and appropriate medication storage by the DON/Designee at orientation as a part of the systematic changes. (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 Director of Nursing/Designee will conduct audits of medication carts and medication weekly for 4 weeks, then once a week for 4 weeks, and then monthly for 1 month to ensure that there are no expired or outdated medications present and medications are stored properly. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Medication Error Rate Exceeds 5% Due to Improper Crushing of Extended-Release Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by federal regulations, resulting in an observed error rate of 8% out of 25 opportunities. During medication administration, an LPN was observed crushing and administering two extended-release medications to a resident, despite both medications being contraindicated for crushing. The physician's order allowed for medications to be crushed or diluted unless contraindicated, but the extended-release formulations specifically should not have been altered in this way, as confirmed by reference sources and the facility's consultant pharmacist. The facility's policies require medications to be administered according to prescriber orders and for staff to consult with a physician or pharmacist if there are concerns about medication appropriateness or potential adverse consequences. Both the consultant pharmacist and the Director of Nursing confirmed that the extended-release medications should not have been crushed and that alternative formulations or orders should have been sought. The incident was identified during an unannounced recertification survey, and the deficiency was based on direct observation, record review, and staff interviews.
Plan Of Correction
F759-Free of Medication Error Rate of 5% or More (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On Staff A was educated regarding medication administration and the "Do not Crush" list on medication cart. On Resident #22 was assessed by a licensed nurse with no negative findings. MD was notified of medication error with orders received to change the form of the 2 identified medications. Started treatment on . (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On Audit was completed by Director of Nursing/designee on current residents to identify if medications needed to be crushed. Any identified meds were changed to the appropriate form. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By , Current Licensed Nurses will be educated on the components of F759 with an emphasis on being aware of what medications can be crushed and which medications can not be crushed as well as overall medication administration practices by the DON/Designee. Newly hired licensed Nurses will be educated on the components of F759 with an emphasis on being aware of what medications can be crushed and which medications can not be crushed as well as overall medication administration practices by the DON/Designee at orientation as a part of the systematic changes. (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: Director of Nursing/Designee to conduct observations of medication administration 3x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that licensed Nurses are administering medications properly. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Provide Required RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) provided services for at least 8 consecutive hours per day, 7 days a week, as required by federal regulations. Record review of staffing forms and RN time sheets revealed that on two separate days, the number of RN hours worked fell below the required 8 consecutive hours. Specifically, on one day, only 7.87 hours were worked, and on another, only 5.42 hours were worked. Further examination of RN time sheets confirmed that on these days, the RN clocked in and out in a manner that resulted in less than the required consecutive hours of coverage. Interviews with the Labor Coordinator and the Nursing Home Administrator confirmed that no other RN worked on those days to supplement the hours, and there were no call-offs reported. The Labor Coordinator acknowledged the discrepancy as a mistake, and the Administrator verified the shortfall in RN coverage. The deficiency was identified through review of facility records and staff interviews, with no mention of resident-specific incidents or medical histories related to the deficiency.
Plan Of Correction
F727-RN 8 Hrs/7 days/wk What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Administrator completed a comprehensive review of RN hours for the previous 2 weeks and found that there were 8 consecutive hours of RN coverage. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On , Audit was completed by Administrator/designee of Staffing hours for past 2 weeks to ensure that Staffing requirements are met, Including 8 consecutive RN hours every day of the week day. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By /205, the Staffing coordinator, Administrator and Human Resources and Director of Nursing will be educated on the components of F727 with an emphasis on 8 consecutive hours seven days a week of RN hours per day and schedule requirements by the Regional Vice President of Operations/Designee. (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: Administrator/Designee to conduct audits of staffing report 5x a week for 4 weeks, then 2x a week for 4 weeks and then monthly for 1 month to ensure that Staffing requirements are met and that there are 8 consecutive RN hours every day of the week. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Administer Insulin and Monitor Blood Glucose per Physician Orders
Penalty
Summary
A deficiency was identified when the facility failed to follow physician's orders for the monitoring and administration of insulin for one resident. The resident, who had diagnoses including diabetes and was dependent on insulin, had physician orders for both long-acting and short-acting insulin, with specific instructions to check blood glucose prior to the administration of the 11:30 AM dose of short-acting insulin. The Medication Administration Record (MAR) showed that the 11:30 AM dose and the required blood glucose monitoring were missed on five out of fourteen occasions when the resident was out of the facility for dialysis. Interviews with the Director of Nursing (DON) revealed that the resident routinely left the facility three times a week for dialysis, departing by 10:00 AM and returning around 3:00 PM. The DON was not aware if the physician knew that the resident was missing the 11:30 AM insulin dose and associated blood glucose checks on those days. The DON acknowledged that the nurse documented the missed doses and monitoring but had not clarified the order with the prescribing physician to address the resident's regular absence during the scheduled administration time. The resident's primary physician confirmed awareness of the resident's dialysis schedule and insulin regimen but believed that blood glucose should be checked more frequently and that the missed doses were likely due to an oversight in order clarification. The physician stated he was under the impression that the resident would receive the insulin and monitoring upon return from dialysis. Staff interviews indicated that missed doses were considered as such and that clarifying the order with the physician would be the best course of action, but this had not been done.
Plan Of Correction
F684 Quality of Care What corrective action(s) will be accomplished for those residents found to have been affected by this practice? On medication review completed with NP. How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? On , Director of Nursing/designee completed an audit of all resident residents receiving to ensure supplemental orders are in place. On , Director of Nursing/designee completed an audit of all resident receiving to ensure a medication review has been completed. What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? By the Director of Nursing/ designee completed education with the licensed nursing staff regarding supplemental for monitoring, what to do if a medication is scheduled while a resident is at . How will the corrective actions be monitored to ensure the practice will not recur; what quality measures will be put into place? Director of Nursing/designee to complete random audit to ensure resident receiving have supplemental orders, weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. Director of Nursing/designee to complete random audit to ensure a medication review has been conducted for resident receiving weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. Findings will be reported monthly at the QA/Risk management meeting until such a time substantial compliance has been determined. The practice will not recur; what quality measures will be put into place? Director of Nursing/designee to complete random audit to ensure resident receiving have supplemental orders, weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. Director of Nursing/designee to complete random audit to ensure a medication review has been conducted for resident receiving weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. Findings will be reported monthly at the QA/Risk management meeting until such a time substantial compliance has been determined.
Failure to Provide Ordered Range of Motion and Brace Application
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent a decline in range of motion for a resident with significant physical and cognitive impairments. The resident, who had a history of hemiplegia, hemiparesis, and aphasia, was dependent on staff for activities of daily living and had documented functional limitations in the upper and lower extremities on one side. The care plan and physician's orders specified that the resident should receive passive range of motion (PROM) exercises and application of a brace to the affected limb, with specific instructions for timing and monitoring. However, observations revealed that the resident did not have the prescribed device in place, and staff interviews indicated a lack of awareness or implementation of the required interventions. Review of documentation, including the Treatment Administration Record (TAR) and CNA Kardex, showed no evidence that PROM or brace application had been performed as ordered. Staff interviews confirmed that the interventions were not being carried out, and the Director of Nursing verified the absence of documentation for these treatments. As a result, the facility did not meet the licensure requirement to provide adequate and appropriate health care and services consistent with the resident's care plan and physician's orders.
Plan Of Correction
F688 Increase/Prevent Decrease in ROM/Mobility (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On , Resident # 31 was assessed by a licensed nurse. No concerns were noted related to the alleged deficient practice. On , the order was clarified with MD to indicate donning and doffing of , as well as performing PROM. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: On Audit was completed by Director of Nursing/designee on residents who had orders for /braces to ensure order indicated donning and doffing equipment. Any issues identified were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: By , Current Nurses and staff will be educated on the components of F688 with an emphasis on documenting the donning and doffing of a /brace and following the comprehensive resident centered care plan and Prevention of decrease in ROM/Mobility by the DON/Designee. Newly hired licensed nurses/ , Staff will be educated on the components of F688 with an emphasis on documenting the donning and doffing of a /brace and following the comprehensive resident centered care plan and prevention of decrease in ROM/Mobility by the Director of Nursing/Designee at orientation as a part of the systematic changes. (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: Director of Nursing/Designee to conduct audits of 5 residents with physician orders for a /brace 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that the physician order includes documentation of donning and doffing /brace. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Fire-Rated Door in Hazardous Area Improperly Propped Open
Penalty
Summary
During a facility tour conducted with the Director of Maintenance (DOM) and the Administrator, surveyors observed that a fire-rated door in the kitchen exit passage leading into a hazardous dry storage room was not maintained in accordance with NFPA 101 standards. The door, which is protected by a one-hour fire barrier and equipped with a self-closing device, was found to be held open by a bungee cord wrapped around the door handle. Additionally, a storage rack was positioned in such a way that it further restricted the door from self-closing and latching as required. The Administrator, when interviewed at the time of the observation, confirmed the findings and acknowledged that the door should be kept closed. The report specifies that such doors are only permitted to be held open by an automatic release device that complies with NFPA 101 section 7.2.1.8.2, which ensures the door will close automatically upon activation of the fire alarm, sprinkler system, smoke detection system, or loss of power. In this instance, the door was not equipped with such a device and was instead manually propped open, which is not compliant with the cited regulations. No information was provided in the report regarding any residents or staff being directly affected at the time of the deficiency, nor was there mention of any medical history or specific conditions related to individuals in the facility. The deficiency was based solely on the physical observation of the door's condition and the facility's failure to maintain required fire safety standards for doors with self-closing devices in hazardous areas.
Plan Of Correction
1) No residents were identified. 2) No residents were identified. 3) Administrator immediately discarded bungee cord found to be propping fire door open on 08/04/2025. An in-service education was conducted by the Administrator, Director of Plant Operations, or designee on 08/21/2025 with staff addressing the maintaining doors with self-closing devices in accordance with NFPA 101 (2012 Edition). 4) The Director of Plant Operations, or designee, will audit at random five (5) Fire Rated Doors to observe if the door is free from devices that would prevent self-close and latch. Audits will be conducted once a week for four weeks, once a month for two months, or until substantial compliance is achieved. The results of the audit will be forwarded to the Quality Assurance Committee for review monthly for at least three months with a goal of 100% compliance. Upon completion and 100% compliance for at least three months is achieved, the frequency of further review and ongoing need for review will be determined by the QAPI committee. The same information is repeated in the original text, so it is presented here as a continuous paragraph for clarity.
Commercial Cooking Equipment Not Properly Secured
Penalty
Summary
During a facility tour conducted with the Director of Maintenance (DOM) and the Administrator, it was observed that three gas-fed appliances mounted on casters under the commercial cooking hood were not properly secured. Although each appliance had a restraint tether attached, none of the tethers were connected to the installed wall attachments located behind the appliances. The DOM confirmed these findings during the inspection by visually checking behind the appliances and acknowledging that the tethers were not attached to the wall as required. This lack of proper restraint for the gas-fed appliances constitutes a failure to maintain commercial cooking equipment in accordance with NFPA 101, NFPA 96, and NFPA 54 standards. The deficiency was identified in both buildings referenced in the report, with all three appliances in each building found in the same non-compliant condition. No information regarding residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
1) No residents were identified. 2) No residents were identified. 3) Restraint tethers immediately attached and secured to wall attachments located behind appliances on 08/04/2025 at 1:55 PM by Director of Plant Operations or designee. An in-service education was conducted by the Administrator, Director of Plant Operations, or designee on 08/21/2025 with dining staff addressing the commercial cooking equipment in accordance with NFPA 101 (2012 Edition). 4) The Director of Plant Operations, or designee will audit commercial cooking equipment in accordance with NFPA 101 (2012 Edition) to observe restraint tethers attached and secured to wall attachments located behind appliances. Audits will be conducted once a week for four weeks, once a month for two months, or until substantial compliance is achieved. The results of the audit will be forwarded to the Quality Assurance Committee for review monthly for at least three months with a goal of 100% compliance. Upon completion and 100% compliance for at least three months is achieved, frequency of further review and ongoing need for review will be determined by the QAPI committee.
Failure to Prevent Misappropriation and Inaccurate Documentation of Controlled Substances
Penalty
Summary
The facility failed to protect residents' rights to be free from misappropriation of property by not maintaining effective processes to prevent the misappropriation of controlled substances for two residents. For one resident, a physician's order specified a controlled substance to be administered four times daily, but pharmacy records and controlled substance logs revealed that the medication was being signed out and documented as administered more frequently than prescribed, with some days showing up to 11 doses. The controlled substance logs were found to have multiple dates scribbled over or written illegibly, making it difficult to determine the actual administration times and dates. Despite the discrepancies, the physical count of medication matched the expected amount, but the documentation did not align with the prescribed administration schedule. A similar issue was identified for another resident, where the controlled substance record of use also showed illegible and out-of-order dates, and the number of tablets signed out did not match the administration history. The logs indicated that more tablets were being signed out than were actually administered according to the administration history, and the documentation was inconsistent and unclear. The facility's investigation found that these discrepancies were associated with a specific LPN, who admitted to changing dates on medication documents and could not account for multiple signatures or events on the medication cart. The LPN denied taking any pills or overmedicating residents but acknowledged making documentation errors. The deficiencies were discovered when the pharmacy consultant identified that a refill request for a controlled substance was made earlier than expected, prompting an audit of the controlled substance records. The audit revealed that the documentation did not accurately reflect the administration of medication as ordered by the physician, and the logs were not maintained in a legible or orderly manner. The facility's own investigation confirmed the documentation issues and linked them to the actions of the LPN involved.
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.
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