Ansley Cove Healthcare And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Maitland, Florida.
- Location
- 1301 W Maitland Blvd, Maitland, Florida 32751
- CMS Provider Number
- 105886
- Inspections on file
- 28
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 22 (3 serious)
Citation history
Health deficiencies cited at Ansley Cove Healthcare And Rehabilitation during CMS and state inspections, most recent first.
A resident who had lived in the facility for many years died while covered by Medicaid, with a set monthly income and personal needs allowance, and a monthly patient responsibility paid from a joint checking account by the spouse. After the resident’s death, the facility continued to draw the monthly patient responsibility from the joint account and did not refund the overpayment and remaining funds to the spouse within the required 30-day timeframe. Emails showed that the Business Office Manager notified corporate accounting of the death and requested removal from ACH, and that staff knew the spouse was requesting a refund and was owed more than initially thought. Over four months later, leadership confirmed that a refund of $1,905.35 was still owed and had not been processed, in violation of the facility’s own refund policy and federal requirements.
A resident who was totally dependent on staff for all care, including nutrition via g-tube and frequent repositioning, was not properly monitored or cared for during a shift. Staff failed to provide required assessments, did not check for responsiveness, and did not perform necessary care tasks. The resident was later found unresponsive, exhibiting signs of rigor mortis and a low core body temperature, indicating death had occurred hours before discovery. Documentation was inconsistent, and staff interviews revealed care was not provided as required.
A resident with severe cognitive impairment and multiple health conditions was found unresponsive and later determined by EMS and hospital staff to have been deceased for some time, exhibiting rigor mortis. Documentation and staff interviews revealed that required care was not provided during the evening shift, and there were conflicting accounts regarding the discovery and response to the resident's condition. Facility administration failed to conduct a thorough investigation, did not obtain statements from all involved staff or EMS, and delayed required reporting to the State Agency.
A resident with severe cognitive impairment and total dependence on staff did not receive required ADL care, repositioning, or timely assessments during a shift. Staff failed to recognize or respond to a change in condition, did not physically assess the resident for responsiveness, and inaccurately documented care. The resident was later found unresponsive and, according to EMS and hospital records, had been deceased for several hours prior to discovery, exhibiting rigor mortis and hypothermia. This failure to provide care and timely intervention resulted in Immediate Jeopardy.
A facility failed to conduct a QAPI meeting after a resident was found deceased with signs of rigor mortis, despite inconsistencies in staff documentation and an allegation that the assigned CNA did not provide care during a shift. The NHA, DON, and Medical Director were aware of the incident and discrepancies but did not bring the matter to QAPI for review.
Staff provided inconsistent and misleading statements about a resident's death, with conflicting documentation and witness accounts regarding care and the initiation of CPR. High-level personnel failed to ensure truthful reporting, and staff reported being pressured to provide false statements. Allegations of neglect and ethical violations were not reported to authorities, and the facility did not foster effective communication or protect staff from retaliation, resulting in an inadequate investigation of the resident's death.
A resident with a history of falls, cognitive impairment, and on multiple high-risk medications experienced several unwitnessed falls, including one resulting in a head injury, due to the facility's failure to timely identify and implement appropriate fall prevention interventions. Care plans were incomplete or delayed, fall risk assessments were inaccurate, and supervision was inadequate, leading to actual harm.
A resident with cognitive impairment, mobility deficits, and a history of falls did not receive timely or appropriate fall prevention interventions. Despite being on high-risk medications and having multiple risk factors, the care plan lacked a fall prevention focus for several weeks, and supervision was inconsistent. The resident experienced multiple falls, including one resulting in a head injury, due to inadequate implementation of the facility's fall prevention protocols.
The facility did not maintain an effective QAPI/QAA program, failing to identify and address repeated deficiencies or ensure complete monitoring documentation for corrective action plans. Despite previous enforcement actions for issues such as abuse, neglect, and accident hazards, the QAPI committee did not systematically monitor or document corrective actions, and frequent changes in the DON role contributed to a lack of sustained oversight.
The facility did not ensure the DON followed ethical and professional standards, as the DON backdated evaluations with incorrect documentation and lacked evidence of required education or competency training. Compliance program materials were not accessible to all staff, and key compliance documentation was missing from the DON's file.
A resident with moderate cognitive impairment and a history of falls did not have accurate or timely fall risk assessments or a fall prevention care plan due to backdated and incorrect documentation by the former DON and inaccurate MDS coding by the MDS Coordinator. Despite multiple unwitnessed falls and use of high-risk medications, the resident's risk scores were not updated, and individualized interventions were missing from the care plan.
A resident with cognitive and physical impairments, on blood thinner medication, experienced two unwitnessed falls in an LTC facility due to inadequate supervision by CNAs. The facility failed to initiate timely neurological checks or notify the physician after the second fall, despite the resident developing a hematoma. Insufficient staff education and supervision processes contributed to the neglect and harm experienced by the resident.
A resident with cognitive and physical impairments, on blood thinners, experienced two falls in the activity room due to inadequate supervision. Despite being a known fall risk, the resident was left unattended, resulting in a bruise and hematoma after the second fall, necessitating hospital transfer. The care plan was not updated to reflect the need for increased supervision, and interventions were insufficient.
The facility failed to maintain adequate staffing levels to meet the care needs of residents, many of whom required significant assistance. Observations and staff interviews revealed that CNAs were rushed, call light response times were delayed, and supervision for residents at risk for falls was insufficient. The facility's administration was reportedly unaware of the staffing issues, which were based on census numbers rather than actual care needs, leading to overwhelmed staff and compromised resident care.
A resident with severe cognitive impairment and on anticoagulant medication fell in a facility's activity room. The nurse assessed the resident but failed to promptly notify the physician or escalate the issue when the APRN did not respond. The physician discovered a hematoma during routine rounds the next day, highlighting a lapse in following the facility's notification protocol.
A resident at high risk for falls experienced two unwitnessed falls in the activity room due to inadequate supervision and failure to follow the facility's abuse and neglect policy. The DON did not consider the incidents as neglect, and the facility did not report them. The Administrator later acknowledged the lack of detail in the investigation and the need for more rigorous questioning.
The facility failed to provide adequate ADL care for three residents, including fingernail and oral care, and dressing. A resident with severe cognitive impairment had long, dirty fingernails, while another reported her nails had not been cut since admission. A third resident was observed with poor oral hygiene and soiled clothing. The facility's policy required regular grooming and hygiene services, but staff failed to adhere to these standards, resulting in inadequate care.
The facility failed to provide private access to telephones and internet for three residents, impacting their ability to communicate with family. Residents had to use public phones without privacy, and management did not formally address the issue, which arose from a service disconnection due to an unpaid balance. Staff confirmed the lack of communication and privacy, contrary to facility policy.
The facility failed to properly store and maintain sanitary conditions for food items in both the main kitchen and resident pantry. Observations revealed opened and undated food packages, expired items, and unsanitary conditions in the resident pantry's refrigerator. The Food and Nutrition Manager and a kitchen aide acknowledged the issues, highlighting lapses in food handling and cleanliness protocols.
The facility failed to update PASARR Level I Screens for two residents with new mental disorder diagnoses. One resident, diagnosed with dementia and major depressive disorder, did not have an updated PASARR despite being non-verbal and requiring assistance for daily activities. Another resident, diagnosed with bipolar disorder, also lacked an updated PASARR. The DON confirmed the oversight and acknowledged the absence of a facility policy on PASARR updates.
A facility failed to request a PASARR Level I and Level II evaluation for a resident admitted with Alzheimer's, anxiety, and psychotic disorders. The DON could not locate the PASARR in the medical record and confirmed it was missing. The DON and Administrator determined it was likely lost or misplaced, and the DON acknowledged responsibility for updating PASARRs, noting the facility lacked a policy on them.
The facility failed to obtain physician orders before administering oxygen therapy and did not maintain oxygen flow rates as ordered for two residents. One resident with COPD received oxygen at a higher flow rate than prescribed, while another received continuous oxygen without an active order. The nursing staff did not verify and adjust oxygen flow rates according to physician orders, leading to incorrect administration of oxygen levels.
A resident with multiple pressure ulcers did not receive proper infection control during wound care. The RN failed to change gloves and perform hand hygiene between treating different wound sites, contaminating the medication container. The facility's policy requires hand hygiene before and after resident contact, which was not followed.
A resident with COPD was found with an Albuterol inhaler at her bedside, which she stated was necessary for managing severe attacks. However, there was no physician order authorizing her to self-administer the medication, nor was there an order for the inhaler itself. The DON confirmed that residents should not have medications at the bedside without an assessment and physician order. The facility's policy required an interdisciplinary team assessment and care plan update for self-administration, which had not been completed for this resident.
A resident in an LTC facility, who was cognitively intact and preferred morning showers, reported receiving only two showers in three weeks, contrary to her preferences and the facility's schedule. The DON confirmed the resident's needs were not met, with documentation showing a lack of showers over the last two weeks, highlighting a failure to provide person-centered care.
A resident with stomach cancer requiring J-tube feeding did not receive necessary nutrition for several days due to communication lapses and procedural oversights. The facility failed to have tube feeding equipment ready upon admission, and there was a delay in transcribing the dietitian's recommendations into the medical record, resulting in unmet nutritional needs.
A resident with epilepsy was prescribed 800 mg of Carbamazepine daily but received only 400 mg due to a transcription error in the facility's records. The resident, feeling unwell, discharged themselves after the facility failed to provide accurate pharmaceutical services, as confirmed by the DON.
Failure to Timely Refund Deceased Resident’s Funds to Representative
Penalty
Summary
The facility failed to refund all monies due to a deceased resident’s representative within 30 days of the resident’s death, as required by regulation and the facility’s own refund policy. The resident had resided in the facility for approximately nine years and was Medicaid-eligible, with a gross monthly income of $1,159.22 and a personal needs allowance of $160.00 per month. Billing records showed that the resident’s husband paid a monthly patient responsibility of $314.92 from their joint checking account. Despite the resident’s death, this patient responsibility continued to be drawn from the joint account in the month following death, 13 days after the resident had passed away. Email correspondence showed that the Business Office Manager notified the corporate office accounting department of the resident’s death and requested removal of the resident from Automated Clearing House (ACH) payments. Additional emails documented that the facility was aware the husband was requesting a refund and that the family was due a larger refund than initially believed. At the time of the survey, over four months after the resident’s death, the Corporate Regional Director of Operations and the Administrator confirmed that the resident’s husband was still owed a refund totaling $1,905.35 and that no refund had been issued. The Administrator stated that the Business Office Manager did not have authority to issue refund checks and that they had been waiting for the corporate office to process the refund, contrary to the facility’s written policy requiring final accounting and conveyance of funds within 30 days of death.
Failure to Provide Necessary Care and Timely Assessment Resulting in Resident Neglect and Death
Penalty
Summary
A facility failed to protect a resident's right to be free from neglect by not providing necessary care and services to a totally dependent resident, resulting in the resident being found unresponsive and exhibiting physical signs consistent with having been deceased for several hours prior to discovery. The resident, an elderly female with severe cognitive impairment, was totally dependent on staff for all activities of daily living, including mobility, nutrition via gastrostomy tube, and required frequent monitoring and repositioning. Despite physician orders for regular care and assessments, documentation and interviews revealed that staff did not provide the required care or timely assessments during the shift preceding the resident's death. On the evening and overnight shifts, multiple staff members failed to adequately monitor or assess the resident. The assigned LPN reported seeing the resident sleeping at various times but did not check for responsiveness or breathing, and documentation was inconsistent with the resident's actual condition and care needs. The CNA assigned to the resident did not provide required care, such as repositioning, and incorrectly documented that the resident was unavailable for care, later admitting to confusing her with another resident. Another CNA arriving for the overnight shift found the resident cold and stiff to the touch but did not report these findings to a nurse. Interviews revealed that staff felt pressured by facility leadership to provide false witness statements regarding the incident. When the resident was eventually found unresponsive, staff initiated CPR and called emergency services, but EMS and hospital records indicated the resident had been deceased for several hours, as evidenced by rigor mortis and a significantly lowered core body temperature. The facility's failure to provide care, timely assess, and recognize a change in the resident's condition, as well as the failure to initiate life-saving interventions in a timely manner, resulted in Immediate Jeopardy. The facility's own policies defined neglect as failure to provide necessary goods and services to avoid harm, and staff interviews and documentation confirmed that required care was not provided.
Failure to Investigate Alleged Neglect and Provide Timely Care
Penalty
Summary
The facility failed to investigate an allegation of neglect and did not ensure staff recognized a change in a resident's condition or provided timely interventions. A resident with severe cognitive impairment, multiple comorbidities including encephalopathy, diabetes, stroke, heart failure, and dementia, and who was dependent on staff for all activities of daily living, was found unresponsive after midnight. Staff initiated CPR and the resident was transferred to the hospital, where EMS and hospital records documented the resident was already in rigor mortis with a core body temperature of 90.7°F, indicating the resident had been deceased for some time before staff intervention. The care plan required repositioning every two hours due to a stage 4 pressure wound, but documentation and staff interviews revealed inconsistencies regarding whether care was provided during the evening shift. Staff interviews and medical record reviews showed that the assigned CNA for the 3 PM to 11 PM shift did not provide care to the resident and documented the resident as not available, despite being assigned to her. Multiple staff accounts conflicted regarding the timing and actions taken during the code blue event, with some staff stating the resident was already deceased and in rigor mortis when found. The facility administration did not conduct a thorough investigation, failing to obtain statements from all involved staff, including the staff member who initially alleged neglect, and did not seek statements from EMS responders. The facility also delayed reporting the incident to the State Agency, submitting the required Immediate and Five Day reports approximately 27 days after becoming aware of the allegation. The Administrator and DON were unable to explain the discrepancies in staff accounts or provide evidence that the resident received timely and appropriate care. They also could not account for the delay in reporting the incident or the lack of a comprehensive investigation, including not interviewing key witnesses or considering the hospital's findings of rigor mortis. There was no evidence that the facility addressed potential neglectful actions prior to or during the code blue event.
Failure to Provide Timely Assessment and Care Resulting in Resident Death
Penalty
Summary
A deficiency occurred when facility staff failed to provide care and services in accordance with a resident's care plan, preferences, and professional standards of practice. The resident, who had severe cognitive impairment, was totally dependent on staff for all activities of daily living, and required continuous tube feeding, routine hydration, and frequent monitoring, was not properly assessed or cared for during a specific shift. Staff did not perform required ADL care, repositioning, or timely assessments, and failed to recognize or respond to a change in the resident's condition. Documentation was inconsistent, with some staff noting the resident was 'not available' for care, while others admitted to not providing care or confusing the resident with another individual. During the shift in question, the assigned nurse administered medications via g-tube but did not physically assess the resident for responsiveness or breathing. The CNA assigned to the resident did not provide any ADL care, did not reposition the resident, and incorrectly documented the resident as unavailable. Another CNA, upon starting her shift, found the resident cold and stiff to the touch but did not report this to nursing staff. When the resident was eventually found unresponsive, staff initiated CPR and called EMS, but EMS and hospital records indicated the resident had been deceased for several hours prior to discovery, exhibiting rigor mortis and a significantly lowered body temperature. Interviews with staff revealed a lack of timely and appropriate assessment, failure to follow care plan interventions, and inaccurate or delayed documentation of care and vital signs. There was also a lack of clear communication and role assignment during the emergency response. The facility's policies required accurate documentation and care based on comprehensive assessment, but these were not followed. The failure to provide timely care, recognize a change in condition, and initiate life-saving interventions resulted in Immediate Jeopardy for the resident.
Failure to Conduct QAPI Review After Resident Death and Alleged Neglect
Penalty
Summary
The facility failed to conduct a Quality Assurance and Performance Improvement (QAPI) meeting after allegations of neglect and concerns were identified regarding the death of a resident. The resident was found unresponsive just after midnight, and staff initiated CPR before transferring the resident to the hospital. Hospital and EMS records indicated the resident exhibited signs of rigor mortis and a low core body temperature, suggesting the resident had been deceased for some time prior to being found. There were inconsistencies in staff witness statements, documentation, and timelines regarding when the resident was last cared for and when CPR was initiated. The Nursing Home Administrator (NHA) acknowledged responsibility for monthly QAPI meetings and stated that incidents such as neglect and abuse were typically brought to these meetings. However, the NHA did not bring this incident to QAPI, citing no concerns with staff performance during the code blue event. The Medical Director and DON were aware of the circumstances and documentation discrepancies, including a CNA's false documentation that the resident was not in the facility during the relevant shift. Despite being aware of an allegation of neglect, the facility did not address the incident through the QAPI process.
Failure to Ensure Ethical Practices and Accurate Reporting in Resident Death
Penalty
Summary
The facility failed to ensure staff adhered to ethical practices and professional standards, resulting in inconsistent and misleading statements regarding the circumstances of a resident's death. Staff provided conflicting accounts about the last time the resident was observed, the care provided, and the initiation of CPR. Documentation in the resident's medical record did not align with staff witness statements, and there were discrepancies in the reported times and actions taken during the code event. For example, one LPN documented that the resident was alert and oriented at a time when she later stated she had not assessed the resident, and a CNA's documentation conflicted with her statements about providing care. Further, high-level personnel oversight was lacking, as evidenced by the failure of the DON and Administrator to ensure accurate and truthful reporting. Staff reported being instructed to provide false witness statements under threat of job loss, and there was evidence that the crash cart was placed in the resident's room prior to EMS arrival to give the impression that CPR was in progress. The DON and Administrator denied knowledge of the resident being deceased prior to CPR and failed to report allegations of neglect and ethical violations when they were brought to their attention by staff. The facility also failed to develop effective lines of communication to encourage immediate reporting of violations without fear of retaliation. When a staff member reported allegations of neglect and unethical behavior, these concerns were not reported to the appropriate authorities. The compliance officer confirmed that ethical behavior was expected, but the facility's actions did not support an environment where staff could report violations without fear. These failures contributed to an inadequate investigation into the resident's death and undermined the facility's compliance and ethics program.
Failure to Implement Timely and Appropriate Fall Prevention for High-Risk Resident
Penalty
Summary
A resident with a history of falls, cognitive impairment, and multiple high-risk medications was admitted to the facility and experienced several unwitnessed falls, one of which resulted in a head injury requiring emergency care. Despite documented risk factors such as previous falls, use of opioids, anti-anxiety, and antidepressant medications, and significant physical and cognitive deficits, the facility failed to timely identify and implement appropriate fall prevention interventions. The resident's care plan did not include a fall prevention focus for over six weeks after admission, and interventions were not consistently updated or individualized following each fall. The facility's assessments and documentation were inconsistent and incomplete. Fall risk evaluations repeatedly scored the resident as moderate/low risk, even after multiple falls, and did not reflect the resident's actual fall history or changes in condition. There was a lack of timely and accurate care planning, with missing or backdated assessments and omitted interventions related to the resident's medication regimen and fall risk. Staff interviews revealed that supervision practices were inadequate, with residents, including the affected individual, left unsupervised in wheelchairs near the nurses station, especially during busy periods such as medication pass and shift changes. Family members and staff expressed concerns about the lack of supervision and the resident's inability to use the call light due to cognitive impairment. The care plan interventions, such as encouraging call light use, were not appropriate for the resident's condition. The facility did not have a formal falls prevention program, and communication among staff regarding fall risks and interventions was informal and insufficient. These failures resulted in actual harm to the resident, who suffered a fall with injury.
Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement appropriate interventions to provide adequate supervision and prevent falls with injury for a resident with a known history of repeated falls and high-risk medication use. The resident, an elderly female with generalized muscle weakness, impaired mobility, moderate cognitive impairment, and a history of falls, was admitted from an acute care hospital. Despite multiple risk factors, including cognitive deficits, incontinence, and use of high-risk medications such as antidepressants, opioids, and antiplatelets, the facility did not timely initiate or update a comprehensive fall prevention care plan. For over six weeks after admission, there was no fall prevention focus in the care plan, and interventions were limited to keeping the call light within reach, which was not appropriate given the resident's cognitive impairment. Observations and interviews revealed that the resident experienced multiple falls during her stay, including an unwitnessed fall from a wheelchair near the nurses' station that resulted in a head laceration requiring emergency care. Staff interviews indicated that while it was common practice to place high fall risk residents near the nurses' station, supervision was inconsistent, especially during busy periods such as medication pass and after dinner. Staff also reported that care plan interventions and safety directives were not always clearly communicated or documented in the electronic record, leading to reliance on verbal reports and inconsistent implementation of fall precautions. Record review and staff statements confirmed that the facility's fall prevention program and protocols were not followed as required. The resident's care plan was not updated in a timely manner to reflect her fall risk, and interventions were not adequately tailored to her needs, particularly given her cognitive impairment and inability to reliably use the call light. The facility's own guidelines required standardized risk assessments, increased supervision, and prompt care plan updates, but these measures were not effectively implemented, resulting in actual harm to the resident.
Failure to Maintain Effective QAPI Program and Monitoring Documentation
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) program by not identifying and addressing repeated deficiencies and by not ensuring complete monitoring documentation for corrective action plans. Previous surveys had resulted in enforcement actions for deficiencies related to abuse and neglect, failure to investigate and correct alleged violations, and accident hazards. Despite these repeated issues, the QAPI committee did not systematically monitor or document the progress of corrective actions, and there was a lack of sustained oversight, particularly due to frequent changes in the Director of Nursing (DON) position. The Nursing Home Administrator (NHA) was unable to provide documentation of completed Performance Improvement Plans (PIPs) or explain how substantial compliance was determined for previous citations. The facility's own guidelines required ongoing, systematic monitoring of performance indicators and data collection for at least one year, but these processes were not followed. The NHA acknowledged that the DON was responsible for ensuring nursing-related corrective actions were active and sustained, but admitted there was a failure to track and implement these measures. As a result, the facility did not have an effective system in place to ensure that identified problems were corrected and prevented from recurring, and monitoring documentation was incomplete or missing.
Failure to Ensure Compliance and Ethics Program Adherence by DON
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) adhered to ethical expectations and professional standards, as evidenced by backdating evaluations with incorrect documentation. There was no evidence that the DON had received education or competency training for the role, nor was there documentation of the DON's signed job description or acknowledgement of Compliance and Ethics Program orientation education. The Human Resource Assistant, who also served as the Compliance Officer, stated that compliance program information was provided during employee orientation, but did not participate in clinical or resident care meetings and only became involved in employee-related situations such as investigations or terminations. Additionally, compliance program posters, which should have been readily visible for employees, were only present on the Assisted Living Facility side of the building and not on the Skilled Nursing side. The Nursing Home Administrator confirmed that the required compliance documentation for the former DON was missing from the employee file. The facility's own standards outlined the need for sufficient resources, ongoing communication, and annual training to promote quality care, but these requirements were not met as described in the findings.
Failure to Maintain Accurate and Complete Medical Records and Fall Risk Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, resulting in incorrect documentation and backdating of records by the former Director of Nursing (DON). The DON backdated Fall Risk Evaluations and did not update risk scores after the resident experienced multiple unwitnessed falls. These assessments were not completed in a timely manner and did not reflect changes in the resident's condition, such as prior fall history and subsequent falls, which should have increased the fall risk score to a high-risk category. The DON also failed to ensure that individualized care plan interventions were documented, and the Fall Risk Evaluations remained at a moderate/low risk score despite evidence to the contrary. The Minimum Data Set (MDS) Coordinator inaccurately recorded the resident's fall history in the MDS assessments, failing to thoroughly check all medical records. This led to incorrect coding of fall history and the absence of a timely fall prevention care plan. The resident, a 58-year-old female with moderate cognitive impairment, generalized muscle weakness, difficulty walking, and a history of falls, did not have a fall prevention care plan focus developed for over six weeks after admission. The MDS Coordinator acknowledged these errors during interviews and confirmed that the previous coordinator missed critical information regarding fall history and high-risk medication use. The medical record review showed inconsistencies between the resident's actual condition and the documentation in the clinical record. Despite the resident's history of falls and use of high-risk medications, the care plan did not address fall prevention in a timely manner, and the risk assessments were not updated to reflect changes in the resident's status. The DON and nurses' job descriptions required accurate and timely documentation, which was not met in this case, compromising the integrity of the resident's medical information.
Neglect in Fall Prevention and Monitoring
Penalty
Summary
The facility failed to provide necessary care and services to prevent falls and ensure appropriate post-fall monitoring for a resident with cognitive and physical impairments. This resident, who was on blood thinner medication and had a history of repeated falls, experienced two unwitnessed falls within a ten-day period. On both occasions, the resident was left unattended in the activity room by CNAs who were supposed to supervise her as part of the fall prevention program. The first fall occurred when a CNA left the room to give another resident a shower, and the second fall happened when a CNA left the resident alone to respond to a call light. After the second fall, the assigned nurse failed to initiate neurological checks or notify the physician until nearly 12 hours later, despite the resident developing a bruise and a hematoma on her forehead. The resident, who was at high risk for intracranial hemorrhage due to her anticoagulant therapy, was not appropriately monitored, and the developing hematoma went unnoticed until the following day. The facility's Director of Nursing confirmed that the resident's physician was not informed of the fall in a timely manner, and the resident remained in the facility without adequate monitoring. The facility's failure to maintain effective processes for educating staff and offering adequate supervision placed all residents at risk for injury. The education on expectations for the fall prevention program was insufficient, as only a small portion of the nursing staff received the in-service, and no activities staff were included. This lack of comprehensive training and supervision contributed to the neglect of the resident's needs and the subsequent harm she experienced.
Inadequate Supervision Leads to Resident Falls and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls and fall-related injuries for a resident with cognitive and physical impairments. The resident, who was on blood thinner medication and had a history of repeated falls, was left unattended in the activity room on two separate occasions, resulting in falls from her wheelchair. The first incident occurred when a CNA left the resident to attend to another resident, and the second incident happened when the resident was left alone while the RN was attending to another emergency. The resident's medical history included atrial fibrillation, stroke, lack of coordination, repeated falls, generalized muscle weakness, unsteadiness on her feet, right knee contracture, anxiety disorder, paranoid schizophrenia, and Alzheimer's disease. Her cognitive impairment was severe, as indicated by a low score on the Brief Interview for Mental Status. Despite being identified as a high fall risk, the resident's care plan was not adequately updated to reflect her need for increased supervision, and interventions such as a non-slip pad for her wheelchair were deemed insufficient. The facility's failure to monitor the resident closely resulted in actual harm, as the resident suffered a bruise and a hematoma on her forehead after the second fall, requiring hospital transfer for diagnostic testing. The facility's protocols for fall prevention were not effectively implemented, as evidenced by the lack of supervision and the absence of timely neurological checks and physician notification following the falls.
Inadequate Staffing Levels Impact Resident Care and Safety
Penalty
Summary
The facility failed to maintain sufficient staffing levels to provide adequate supervision and meet the care needs of residents, as observed during a survey. The facility had 39 licensed beds with an average daily census of 32 residents, many of whom required significant assistance with activities of daily living. Despite this, the facility was often staffed with only three CNAs on the day and evening shifts, and two to three on the night shift, which was insufficient given the high acuity of care required by the residents. Observations revealed that CNAs were rushed, call light response times were delayed, and staff were unable to provide the necessary care and supervision, particularly for residents at high risk for falls. Interviews with staff, including CNAs and nurses, highlighted the challenges faced due to inadequate staffing. CNAs were required to rotate through the activity room to supervise residents at risk for falls, leaving only two CNAs on the floor to manage other residents' needs. This rotation system significantly impacted their ability to provide timely care, complete tasks such as showers, and respond to call lights. Staff expressed concerns about being overwhelmed and unable to meet the care needs of their assigned residents, with some residents having to wait for assistance or not receiving the necessary care. The facility's administration, including the Administrator and DON, were reportedly unaware of the extent of the staffing issues and the impact on resident care. The staffing coordinator confirmed that staffing decisions were based on census numbers rather than the actual care needs of residents, and acknowledged that the workload would be more manageable with additional CNAs. Despite staff complaints and the evident strain on care delivery, the facility continued to operate with insufficient staffing levels, particularly during the evening shift when resident behaviors associated with dementia increased.
Failure to Notify Physician of Resident Fall
Penalty
Summary
The facility failed to promptly notify the physician of an unwitnessed fall involving a resident at high risk for bleeding. The resident, a female with severe cognitive impairment and multiple diagnoses including atrial fibrillation and Alzheimer's disease, was on anticoagulant medication, increasing her risk for bleeding. On the night of the incident, the resident fell in the activity room, and although the attending physician was notified, the time of notification was not documented. The physician assessed the resident almost 12 hours later, discovering a hematoma on her forehead, and ordered her to be sent to the hospital for evaluation. The incident occurred when the resident was left unattended in a common area despite being agitated, leading to her fall from a wheelchair. The assigned nurse, RN M, heard the resident moaning and found her on the floor. Although RN M assessed the resident and found no immediate injuries, she only attempted to notify the Advanced Practice Registered Nurse (APRN) once and did not receive a callback. The nurse did not make further attempts to contact the physician or APRN, nor did she escalate the situation to the Director of Nursing (DON) as per facility policy. The following morning, the attending physician discovered the resident's hematoma during routine rounds. The facility's policy required nurses to notify the physician immediately after a fall, especially for residents on blood thinners due to the risk of brain bleeding. The DON confirmed that the nurse did not follow the protocol of making multiple attempts to contact a provider or escalating the issue if no response was received. The job descriptions for both RN and LPN staff emphasized the importance of timely and accurate reporting of incidents and changes in resident conditions.
Failure to Investigate and Supervise Leads to Repeated Falls
Penalty
Summary
The facility failed to implement its abuse and neglect prohibition policy and procedures, specifically in conducting a thorough investigation of a fall with injury to rule out neglect and determine if reporting was necessary. A resident, who was at high risk for falls due to conditions such as atrial fibrillation, stroke, and Alzheimer's disease, experienced two unwitnessed falls in the activity room. The first fall occurred when the resident was left unattended by a CNA who left to attend to another resident, and the second fall happened under similar circumstances when the resident was again left unattended. The facility's policies required timely and thorough investigations of all incidents, but the investigation into the resident's falls was inadequate. The DON acknowledged that the CNAs did not follow instructions to ensure the resident's safety, and the resident was not monitored closely for bleeding after the fall. Despite these findings, the DON did not consider the incidents as neglect, and the facility did not report them as such. The Administrator, responsible for implementing the abuse and neglect policy, relied heavily on the DON's findings and did not identify the possibility of an inappropriate or ineffective plan of care. The facility's failure to conduct a thorough investigation and ensure adequate supervision for the resident led to repeated falls and potential neglect. The care plans did not reflect the resident's need for increased supervision, and the facility did not identify or address the root cause of the falls. The Administrator later acknowledged the lack of detail in the investigation and the need for more rigorous questioning to ensure incidents met reporting criteria.
Inadequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) care for three residents, specifically in the areas of fingernail care, oral care, and dressing. Resident #2, a female with severe cognitive impairment, was observed with long, uneven, and dirty fingernails, despite being dependent on staff for personal hygiene. There was no documentation of care refusals, and staff confirmed that nail care should be performed at least twice weekly. Similarly, Resident #5, who was cognitively intact but required substantial assistance, reported her fingernails had not been cut or filed since admission, and staff confirmed that only licensed nurses were allowed to cut nails. Resident #1, who had severe cognitive impairment and required assistance with ADLs, was observed with poor oral hygiene and soiled clothing. Her teeth had plaque, and food particles were visible in her mouth, indicating a lack of regular oral care. The CNA responsible for her care admitted to brushing her teeth only two days prior and acknowledged that her clothing was soiled from a food spill. The Director of Nursing confirmed that CNAs were responsible for personal hygiene tasks and that licensed nurses should supervise and ensure necessary care is provided. The facility's policy stated that residents unable to perform ADLs independently should receive necessary services to maintain good grooming and hygiene. However, the observations and interviews revealed a failure to adhere to these policies, resulting in inadequate care for the residents involved. The lack of documentation and oversight contributed to the deficiencies in providing essential ADL care, as evidenced by the conditions of the residents' fingernails, oral hygiene, and overall appearance.
Failure to Provide Private Communication Access
Penalty
Summary
The facility failed to provide reasonable access to communication methods, specifically telephones and internet, for three residents. Resident #1's phone and internet stopped working, preventing him from maintaining his usual daily contact with his daughter. Despite a meeting with the Ombudsman and the facility's Administrator, the issue remained unresolved, forcing the family to purchase a tablet for communication, which was less effective. Resident #1's MDS assessment indicated no cognitive impairment and highlighted the importance of private phone use. Resident #2 experienced similar issues, with her room phone being non-functional for weeks, requiring her to use the front desk phone without privacy. Her MDS assessment showed moderate cognitive impairment and emphasized the importance of private phone use. Resident #3, who did not have a cell phone, relied on his room phone, which was also out of order. His son, unable to reach him for a month, expressed frustration over the lack of communication, especially during the holiday season. Resident #3's MDS assessment indicated no cognitive impairment and a preference for private phone use. The facility's staff, including CNAs and RNs, confirmed the residents' inability to use their room phones and the lack of communication from management regarding the issue. The Administrator acknowledged the problem stemmed from a service disconnection due to an unpaid balance after a management change. Despite the availability of phones at the nurses' station and activity room, privacy was not ensured, and no formal notification was given to residents or families about the situation. The facility's policy required phones to be available for private use, accommodating residents' needs, which was not met.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and sanitation of food items in both the main kitchen pantry and the resident pantry. During a tour of the kitchen pantry, it was observed that several dry food packages were opened without any indication of the opened date, expiration date, or discard date. These included an open soy sauce bottle, a bag of crispy onions, tortilla chips, a bag of dry mashed potato mix, and expired tortilla wraps. Additionally, taco shells were found without original packaging, making it impossible to determine their expiration date. The Food and Nutrition Manager, who had recently started working at the facility, acknowledged the responsibility of the kitchen staff to date food items to prevent pests and food-borne illnesses. In the resident pantry, unsanitary conditions were noted, including dirty containers of dry cereal with a sticky brown substance on the lids and an open bag of cereal without a date. The refrigerator contained various food items, some of which were improperly stored, such as a jug of lemonade with a brown stain on the lid and a nutritional supplement bottle that had spilled. The refrigerator was also found to be dirty, with a sticky brown substance on the stainless-steel container and caked-on brown substance in the drawers. Kitchen Aide H admitted that the refrigerator needed cleaning and stated it was cleaned once a week, but acknowledged it might have gotten dirty during the night shift. The Food and Nutrition Manager confirmed the expectation for staff to maintain cleanliness and proper labeling of food items.
Failure to Update PASARR for New Mental Disorder Diagnoses
Penalty
Summary
The facility failed to request updated Preadmission Screening and Resident Review (PASARR) Level I Screens for two residents who received new mental disorder diagnoses. Resident #24 was admitted with acute kidney failure and type II diabetes and later diagnosed with dementia and major depressive disorder. Despite these new diagnoses, an updated Level I PASARR screen was not completed. The resident was non-verbal, required substantial assistance for all activities of daily living, and exhibited behaviors such as restlessness and agitation. The Director of Nursing (DON) confirmed that she was unaware of the requirement to submit a new Level I PASARR for the resident. Similarly, Resident #14, who was admitted with chronic pain, major depressive disorder, generalized anxiety disorder, and heart failure, received a new diagnosis of bipolar disorder. However, this new diagnosis was not included in the Level I PASARR. The resident was treated with Abilify for bipolar disorder, and her care plan included psychiatric evaluations and monitoring for mood and behavior changes. The DON acknowledged the oversight and confirmed that the facility did not have a policy on updating PASARRs.
Failure to Complete PASARR Evaluation for Resident
Penalty
Summary
The facility failed to request a Preadmission Screening and Resident Review (PASARR) Level I and Level II evaluation for a resident reviewed for PASARR. The resident was admitted from the hospital with diagnoses including vascular dementia, Alzheimer's disease, major depressive disorder, and generalized anxiety disorder. The Admission Minimum Data Set (MDS) indicated the resident had severely impaired cognitive skills and was receiving antipsychotic and antidepressant medications. Upon review, the Director of Nursing (DON) could not locate the resident's Level I PASARR in the medical record and confirmed it was not present in the social services tab or elsewhere in the chart. The DON and the Administrator determined that the Level I PASARR was likely lost or misplaced, but they could not confirm if it was ever completed. The DON acknowledged responsibility for updating PASARR and stated that the facility did not have a policy on PASARRs.
Failure to Obtain Physician Orders and Maintain Oxygen Flow Rates
Penalty
Summary
The facility failed to obtain physician orders before administering oxygen therapy and did not maintain oxygen flow rates as ordered by the physician for two residents. Resident #12, who was readmitted with chronic obstructive pulmonary disease (COPD) and required continuous oxygen, was observed receiving oxygen at a higher flow rate than prescribed. The physician's order was for 1 liter per minute, but observations showed the oxygen concentrator set at 4 liters per minute and later at 3 liters per minute. The nursing staff, including LPN B, failed to verify and adjust the oxygen flow rate according to the physician's order, despite being aware of the correct prescription. Resident #29, admitted with chronic kidney disease and other conditions, was observed receiving continuous oxygen therapy without an active physician order. The medical record review revealed no orders for oxygen therapy, and the attending physician confirmed that the resident did not require continuous oxygen and could manage on room air. The staff, including RN G, was unable to find an order for oxygen therapy in the electronic medical record until a verbal order was signed on a later date, indicating a lack of proper documentation and verification of physician orders before administering oxygen. The facility's policy intended to ensure residents received necessary respiratory care in accordance with professional standards and the resident's care plan was not followed. The Director of Nursing acknowledged the failure of the nursing staff to verify and adjust oxygen flow rates as per physician orders, which led to the administration of incorrect oxygen levels to the residents. This deficiency highlights a lapse in adherence to established protocols for respiratory care management within the facility.
Inadequate Infection Control During Wound Care
Penalty
Summary
Facility staff failed to adhere to proper infection prevention and control practices during wound care for a resident with multiple pressure ulcers. The resident, who was admitted with a diagnosis of an unstageable pressure ulcer in the sacral region and other health conditions including MRSA, was receiving hospice care. During an observed wound care session, the Registered Nurse (RN) did not change gloves or perform hand hygiene between treating different wound sites, which is inconsistent with professional standards of practice and the facility's hand hygiene policy. The RN was observed applying barrier cream to the resident's sacral wound and right upper arm without changing gloves or washing hands after removing the old dressing and cleansing the wound. This action contaminated the medication container and potentially spread infection. The RN acknowledged the mistake after the procedure, and the Director of Nursing confirmed that gloves should have been changed between each step of the wound care process. The facility's policy requires hand hygiene before and after resident contact and after contact with contaminated surfaces, which was not followed in this instance.
Failure to Promote Self-Administration of Medication
Penalty
Summary
The facility failed to promote the right to self-administer medication for a resident with chronic obstructive pulmonary disease (COPD). The resident, who was cognitively intact and had no behavioral symptoms, had a hand-held Albuterol inhaler on her tray table, which she stated was necessary for managing severe COPD attacks. Despite the resident's assertion that her doctor wanted her to have the inhaler, there was no physician order authorizing her to self-administer the medication, nor was there an order for the inhaler itself. The Director of Nursing (DON) confirmed that residents should not have medications at the bedside unless assessed and deemed capable of self-administration. The inhaler was removed from the resident's room by the DON, who informed the resident that a nursing assessment and physician order were required for her to keep the inhaler. The facility's policy indicated that residents could self-administer medication if deemed clinically appropriate by the interdisciplinary team, with a physician order and care plan update required, but these steps had not been completed for the resident.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's right to choose the type and frequency of baths, as required by their preferences. A resident, who was cognitively intact and had expressed a preference for morning showers, reported receiving only two showers in three weeks since admission, despite being scheduled for showers twice a week. The resident expressed dissatisfaction with the lack of showers, feeling unclean and noting the absence of disposable wipes for personal hygiene. The Director of Nursing (DON) confirmed that the resident should have been offered showers according to her preferences and acknowledged the failure to meet the resident's needs. Documentation showed the resident received showers only on two specific dates, with no record of showers in the last fourteen days. The DON verified that the resident's experience was unacceptable and emphasized the importance of honoring residents' choices and preferences as part of person-centered care.
Failure to Implement Timely Tube Feeding for Resident
Penalty
Summary
The facility failed to implement necessary interventions to ensure the optimal nutritional status for a resident who required assisted nutrition and hydration via a jejunostomy tube (J-tube). The resident, with a medical history of stomach cancer, was admitted to the facility with specific nutritional needs that included tube feeding. However, upon admission, there was a lack of clear instructions regarding the type or rate of tube feeding formula, and the facility did not have the necessary equipment ready for the resident's arrival. The Director of Nursing (DON) attempted to verify the resident's diet and tube feeding orders with the hospital but was unsuccessful. Consequently, the resident did not receive tube feedings for three to four days after admission, relying instead on thickened liquids and pureed food, which he could not consume adequately. The Registered Dietitian (RD) assessed the resident and recommended a specific tube feeding formula and rate, but the order was not added to the electronic medical record until several days later, delaying the initiation of the tube feeding. The delay in providing the necessary tube feeding was compounded by communication lapses and procedural oversights. The DON contacted the RD late in the day after the resident's admission, and the RD's recommendations were not promptly transcribed into the medical record. Additionally, the facility's policy required the admitting nurse to obtain physician orders for tube feeding and notify the dietitian, but these steps were not effectively executed, resulting in the resident's nutritional needs not being met in a timely manner.
Medication Dosage Error for Resident with Epilepsy
Penalty
Summary
The facility failed to provide accurate pharmaceutical services for a resident who was admitted with a history of epilepsy and a recent fall due to not taking seizure medication on time. Upon discharge from the hospital, the resident was prescribed Carbamazepine 200 mg, to be taken as two tablets in the morning and two at bedtime, totaling 800 mg daily. However, the facility's medical record inaccurately transcribed this order, resulting in the resident receiving only 400 mg daily during their stay. This discrepancy was confirmed by the Director of Nursing (DON) after the resident expressed dissatisfaction with the care and noted feeling unwell due to the incorrect dosage. The facility's interdisciplinary team, responsible for reviewing newly admitted residents' charts, failed to identify the incorrect dosage during their daily clinical meetings. The facility's policy on pharmacy services, which includes procedures to ensure accurate medication administration, was not adhered to, leading to the resident receiving an incorrect dose of Carbamazepine. The DON acknowledged the error and confirmed that the transcription mistake was not caught during the review process, resulting in the resident's decision to discharge themselves due to dissatisfaction with the care received.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
