Aspire At Evans
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Myers, Florida.
- Location
- 3735 Evans Ave, Fort Myers, Florida 33901
- CMS Provider Number
- 106000
- Inspections on file
- 32
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Aspire At Evans during CMS and state inspections, most recent first.
The facility failed to complete individualized baseline care plans within 48 hours of admission for three newly admitted residents. One resident admitted for rehab after a fall had a baseline care plan that was essentially blank, lacking goals, instructions, and any interventions, including those related to a known fall history. Another resident admitted from the hospital with chest pain had an incomplete baseline care plan in which a falls/safety goal was marked but no interventions were documented. A third resident admitted with acute respiratory failure with hypoxia had a baseline care plan with multiple goals (falls/safety, oral/dental, pain, anticoagulant use) circled but no interventions identified. The unit manager and DON confirmed that these baseline care plans were not completed as required by facility policy.
A resident admitted after a fall at home with a closed head injury and transferred for rehabilitation had physician orders for OT, PT, and speech therapy evaluations and treatment that were not completed as directed. Although a wheelchair evaluation and provision occurred shortly after admission, the therapy department did not perform the ordered OT, PT, and speech evaluations within its usual 48-hour timeframe and instead scheduled them for a later date. The evaluations were never carried out because the resident was sent to the hospital for a change in mental status, and both the therapy director and DON confirmed that the physician-ordered therapy evaluations were not completed.
The facility did not maintain an effective pest control program, as evidenced by ongoing reports and direct observations of roaches, ants, and other pests in resident rooms and common areas. Staff and residents described frequent pest sightings, and pest control logs documented repeated infestations despite regular treatments. The persistent presence of pests affected at least two residents and was acknowledged by multiple staff members, indicating a failure to ensure a pest-free environment.
The facility did not consistently assign or document a licensed nurse as charge nurse on evening and night shifts, leading to confusion among nursing staff about supervisory roles and oversight. Staff interviews revealed uncertainty about who was responsible for patient care leadership during these times, and assignment sheets lacked clear identification of a charge nurse.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with severe cognitive impairment and dementia was physically restrained by two CNAs, who held the resident by the head, chest, arms, and feet in an attempt to keep her seated while she was agitated and attempting to get up. This resulted in bruising to the resident's chest and limbs. The incident was observed by an RN, who intervened and reported the event, and facility leadership acknowledged that such restraint was not permitted and constituted abuse.
The facility did not complete required documentation or provide written notification regarding transfer, discharge, appeal rights, or bed-hold policies for three residents who were transferred or discharged. In each case, there was a lack of progress notes, discharge notices, and bed-hold documentation, and staff were unable to provide the necessary records or explain the absence of these documents.
Two residents were not permitted to return to the facility after hospitalization, with missing documentation and unclear decision-making regarding their readmission. Required notifications, such as bed hold and discharge notices, were not provided, and facility staff could not clearly explain or document the reasons for denying return, despite policy and regulatory requirements.
Two dependent residents did not receive scheduled assistance with ADLs, including nail care and showers, as required by facility policy. Both were observed with dirty, untrimmed nails and unkempt hair, and staff interviews confirmed that care was not provided as scheduled, with no refusals documented. The DON and administrator acknowledged that nail care and showers should have been performed according to established routines.
Two residents experienced significant weight loss due to inconsistent meal intake documentation, hindering the evaluation of nutritional interventions. One resident, with a history of dehydration and altered mental status, lost 13% of her weight in two weeks despite interventions. Another resident, with alcohol dependence, faced similar issues, with meal refusals and weight loss not consistently documented. The DON confirmed the lack of documentation and communication, impacting the residents' nutritional care.
The facility failed to prevent avoidable falls and provide adequate supervision for three residents, resulting in serious injuries. A resident with severe cognitive impairment fell and fractured her nose, with the facility failing to consider her claim of being pushed. Another resident with dementia sustained a wrist fracture due to inadequate supervision, and a third resident experienced multiple falls, including a subarachnoid hemorrhage, without specific fall prevention interventions in place.
The facility failed to maintain safe and sanitary food storage and preparation conditions. Unlabeled food items were found in the refrigerator, and staff were not trained to test the sanitizing agent in the dishwasher. Dusty and debris-covered plastic covers were used for clean plates, and dirty ceiling tiles and vents were observed over food preparation areas. The Maintenance Director admitted to not cleaning the vents and tiles monthly as required.
The facility failed to provide a structured activity program for residents in the memory care unit, resulting in a lack of engagement and stimulation for several residents with cognitive impairments. Activities listed on the calendar were not effectively implemented, and residents were often left sitting or wandering without meaningful interaction. Staff struggled to engage residents due to limited resources and familiarity, leading to concerns from family members and a lack of tailored activities to meet residents' needs.
The facility failed to ensure the activities program was directed by a qualified professional. The current Activities Director, Staff B, lacked the necessary qualifications and certification in therapeutic activities, as confirmed by the Human Resources Director and Administrator. Staff B had been in the role for several months without meeting the job requirements, following the departure of the previous Activities Director.
The facility failed to document the completion of 12 hours of continuing competency education for five CNAs in 2023. Despite reminders sent by the HRD, a miscommunication between the HRD and ADON regarding monitoring responsibilities led to this oversight.
The facility failed to provide dignified care to two cognitively impaired residents. One resident, with a fractured wrist, was observed without a required splint, leading to discomfort and agitation during inappropriate public dressing changes by an LPN. Another resident, with dementia, was seen wandering barefoot and with mismatched socks, taking food and personal items without staff intervention. These actions compromised the residents' dignity and care.
The facility failed to maintain a clean and safe environment in the Memory Care Unit, affecting multiple rooms and the dining area. Observations included a strong odor of urine and feces, missing bathroom mirrors, exposed wires, and large holes in walls. Staff interviews revealed a lack of a Maintenance Director and outdated maintenance requests, with the Regional Maintenance Director confirming the issues.
Two residents admitted to the facility did not receive their Baseline Care Plans (BCPs) as required. One resident, with End Stage Renal Disease and Chronic Diastolic Heart Failure, and another with Chronic Obstructive Pulmonary Disease and Malignant Neoplasm of the Liver, were not provided with their BCPs, which should have included initial goals, medication summaries, and dietary instructions. Staff interviews confirmed the absence of documentation and the residents' lack of awareness of their care plans.
A resident with a skin tear on the right wrist was observed with an undated bandage, and there was no documentation of a wound care order or progress notes in the clinical records. Staff interviews confirmed the lack of documentation and physician orders, which could risk infection or worsening of the wound.
A resident with broken teeth did not receive timely dental care, including routine cleanings and partial dentures, due to a lack of coordination by the facility's Social Service Director. The resident had not seen a dental hygienist for several months and was unaware of when she would receive partial dentures, despite a dentist's recommendation. The facility's Social Worker Regional Director confirmed the absence of routine dental care and noted the lack of follow-up for necessary dental procedures.
A resident diagnosed with influenza was not placed in a private room as required by facility policy and CDC guidelines, leading to a deficiency in infection control. The resident was initially placed on contact precautions instead of droplet precautions due to miscommunication among staff, including the ADON, Unit Manager, and DON. The Regional Nurse provided guidance without consulting the facility's infection control policy, assuming the resident was asymptomatic.
The facility failed to ensure that two residents received showers as scheduled and as requested by their families. One resident with dementia and physical impairments had only one documented shower in March 2024, despite a grievance from her granddaughter. Another resident with multiple physical issues also had only one documented shower in the same period, confirming a consistent failure in providing and documenting necessary care.
Failure to Complete Individualized Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement individualized, person-centered baseline care plans within 48 hours of admission for three residents, as required by its Plan of Care Policy and Procedures. The policy, revised on 9/25/17, required that an individualized baseline plan of care be created within 48 hours of admission, including initial goals and interventions based on admission orders, physician orders, dietary orders, therapy services, social services if applicable, and other areas needed to provide effective care until the comprehensive care plan was completed. Record review for one resident admitted for rehabilitation after a fall at home showed that the baseline care plan was essentially blank, containing only the spouse’s signature on one page and lacking any initial goals, instructions, or interventions, including failure to address the resident’s history of falls or to identify goals and interventions to prevent further falls. Record review for a second resident admitted from the hospital with chest pain for rehabilitation services showed that the baseline plan of care had an incomplete first page, and while a goal for falls/safety was circled, no interventions were identified for that goal. For a third resident admitted from the hospital with acute respiratory failure with hypoxia for rehabilitation services, the baseline plan of care also had an incomplete first page, and the goals for falls/safety, oral/dental, pain, and anticoagulant use were circled without any corresponding interventions documented. In interviews, the unit manager stated that the admitting nurse was required to complete a comprehensive assessment and personalized baseline care plan at admission and that she reviewed new admissions the next day to ensure orders, assessments, and baseline care plans with goals and personalized interventions were completed. Both the unit manager and the DON confirmed, upon review, that the baseline care plans for these three residents were incomplete and did not include the required goals and interventions needed to meet residents’ needs until the comprehensive plans of care were completed.
Failure to Provide Ordered Rehabilitation Therapy Evaluations
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered specialized rehabilitative services, specifically occupational, physical, and speech therapy evaluations and treatment, for one resident admitted for rehabilitation following a closed head injury. The resident was discharged from the hospital to the facility on 1/15/26 with a primary diagnosis of closed head injury and with physician orders dated 1/16/26 for OT, PT, and speech therapy evaluations and to treat as indicated. The Medical Certification for Medicaid Long-Term Care and Services and Patient Transfer Form dated 1/14/26 documented that the resident was being discharged to a skilled facility for rehabilitation. The resident’s daughter reported that her father had been hospitalized after a fall at home and that she was informed by the resident and his wife that rehabilitation therapy would not begin until 2/02/26. The Director of Therapy confirmed that although the resident was admitted with therapy orders on 1/16/26, only a wheelchair evaluation was completed on 1/16/26 and a wheelchair was provided that day. She stated that the standard practice was to complete therapy evaluations within 48 hours of admission, but in this case, the PT, OT, and speech evaluations were not performed as ordered and were instead scheduled for 2/02/26. These evaluations were not completed on 2/02/26 because the resident was sent to the hospital that day for a change in mental status. The DON confirmed that the resident had orders dated 1/16/26 for OT, PT, and speech therapy evaluations, which were acknowledged by the primary care physician on 1/21/26, and that these ordered evaluations were not completed as directed by the physician.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, which specifies regular inspection, reporting, and prevention of pest infestations. During an initial tour, surveyors observed two brown bugs crawling up the wall in an occupied resident bathroom. Staff present acknowledged the ongoing presence of pests, with a CNA stating that bugs are seen everywhere and that spraying has not resolved the issue. Multiple residents reported frequent sightings of roaches, including one who described seeing roaches nightly and another who requested a transfer due to the infestation. Staff interviews further confirmed the widespread nature of the problem, with reports of bugs in resident drawers and emerging from air-conditioning units. Review of the facility's pest sighting logs revealed repeated reports of roaches and ants across all nursing units over several months, including sightings in resident rooms, staff breakrooms, and common areas. Pest control service logs indicated treatments were performed, but also documented ongoing issues such as rodent droppings and bed bug treatments. Despite regular pest control visits, staff and maintenance personnel reported that infestations persisted and that immediate action was limited by the availability of pest control services and lack of on-site resources. The facility's failure to effectively address and resolve these pest issues resulted in an environment that was not free from pests for at least two residents.
Failure to Assign and Document Charge Nurse on All Shifts
Penalty
Summary
The facility failed to ensure that a licensed nurse was designated to serve as charge nurse on all shifts, as required. Review of daily assignment sheets for three nursing units over several days revealed that no charge nurse was documented for the 3:00 p.m. to 11:00 p.m. or 11:00 p.m. to 7:00 a.m. shifts. Staff interviews confirmed that there was confusion among nursing staff regarding who was responsible for oversight during these shifts. The Director of Nursing (DON) stated that there was no designated charge nurse at night and that all nurses worked together, while the Assistant Director of Nursing (ADON) indicated that an RN on duty at night was considered the supervisor, but this was not consistently documented on assignment sheets. Further interviews with LPN staff revealed a lack of awareness about who the evening or night supervisor was, with staff unable to identify a designated leader for those shifts. The Administrator also could not confirm who was in charge, deferring to the DON. The DON acknowledged that there was not currently a licensed nurse assigned as supervisor on the evening shifts and confirmed the lack of documentation on assignment sheets. No specific residents or patient conditions were mentioned in relation to this deficiency.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure a safe and abuse-free environment for all residents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent Physical Restraint and Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment and dementia from abuse in the form of physical restraint not required to treat medical symptoms. The incident involved two CNAs who were observed by a registered nurse holding the resident by the head, chest, arm, and feet in an attempt to keep her seated in a chair while she was agitated, screaming, and attempting to get up. The nurse intervened, instructed the CNAs to stop, and assisted the resident out of the chair. The resident was subsequently found to have bruising on her chest, right arm, and hand, as well as on her left forearm and hand. Staff interviews and record reviews confirmed that the CNAs physically restrained the resident, which was not permitted by facility policy and was not required for the resident's medical condition. The facility's policy defines abuse as the willful infliction of injury, and the DON and Administrator acknowledged that physically holding a resident in this manner would be considered a restraint and potentially abuse. The incident was under investigation at the time of the report, and the Administrator indicated it was being treated as an abuse case.
Failure to Provide Required Transfer/Discharge Documentation and Notification
Penalty
Summary
The facility failed to ensure that required documentation and notifications were completed for residents who were transferred or discharged. Specifically, for three residents reviewed, there was no evidence in the medical records of proper documentation regarding the reasons for transfer or discharge, nor were there written notifications provided to the residents or their representatives as required by facility policy and federal/state regulations. The facility policy mandates that in cases of transfer or discharge, especially those initiated by the facility, documentation must be present in the resident's medical record, and written notice must be given to the resident and their representative, including information about appeal rights and bed-hold policies. For one resident, there were no progress notes indicating the reason for transfer or the resident's destination after discharge. The DON and Administrator were unable to provide documentation such as bed-hold or transfer/discharge notices, and there was confusion regarding the resident's readiness to return and the facility's bed availability. Another resident was sent to the hospital for chest pain and subsequently discharged, but the chart lacked further documentation about the resident's status or the facility's decision-making process. Dialogue between the hospital and facility indicated the facility declined to accept the resident back, citing care needs and safety concerns, but no formal notice of discharge was issued. A third resident was sent to the hospital due to a medical issue, but again, there was no documentation in the chart regarding the outcome or any bed-hold notice. Staff interviews confirmed that required documentation, including bed-hold notifications, was not found for any of the three residents. The lack of documentation and notification represents a failure to follow established procedures for resident transfers and discharges.
Failure to Permit Return and Provide Required Discharge Documentation After Hospitalization
Penalty
Summary
The facility failed to permit two residents to remain in or return to the facility following hospitalization, as required by federal and state regulations. For one resident, there was no documentation in the chart indicating the reason for transfer to the hospital or the subsequent discharge process. The DON stated the resident was sent to the hospital due to pain after an incident involving muscle spasticity and shaking, but could not provide required documentation such as a bed hold or transfer/discharge notice. The resident was later transferred to a long-term acute care hospital, and when ready to return, the facility did not have a bed available. The administrator and admissions coordinator could not provide clear reasons for not readmitting the resident, and there was no evidence that the facility assessed bed availability or provided the necessary notifications. For the second resident, the chart indicated a transfer to the hospital for chest pain, but there was no further documentation regarding the resident's status or discharge process. The DON and admissions coordinator gave conflicting accounts, with the DON stating the resident chose to transfer to another facility, while the admissions coordinator referenced care needs and behavioral concerns as reasons for not accepting the resident back. Communication with the hospital revealed the facility cited care needs exceeding capacity and the resident being a danger to self and others, but the DON later stated the resident was not actually a threat and had not been involved in physical altercations. There was also no bed hold documentation or 30-day discharge notice provided for this resident. The facility's own policy requires that residents sent to acute care must be permitted to return unless specific criteria are met, and that appropriate documentation and notifications must be completed. In both cases, the facility did not follow its policy or regulatory requirements, as evidenced by missing documentation, lack of clear decision-making regarding readmission, and failure to provide required notices to the residents.
Failure to Provide Scheduled ADL Care Including Nail Care and Showers
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically nail care and showers, for two dependent residents. According to facility policy, residents are to receive assistance with bathing at least twice a week or as needed, with preferences reviewed quarterly. Documentation showed that one resident, who had severe cognitive impairment, received only four bed baths over a six-week period, with the last recorded on 6/2/25, despite scheduled shower days. Another dependent resident, who preferred showers, received only two showers in the same timeframe, with bed baths substituted despite the documented preference for showers. Observations revealed both residents had disheveled, greasy hair and long, dirty fingernails with debris under and around the nails. Staff interviews confirmed that nail care and bathing were not performed as scheduled, and there was a lack of clarity among CNAs and LPNs regarding nail care routines. No refusals for care were documented for either resident. The DON and facility administrator confirmed that nail care and showers should have been provided according to policy and resident schedules, but this was not done.
Inconsistent Meal Documentation Leads to Nutritional Deficiency
Penalty
Summary
The facility failed to ensure consistent documentation of meal intake for two residents with significant weight loss, which hindered the evaluation of nutritional interventions. Resident #3 was admitted with a history of altered mental status, dehydration, and abnormal laboratory results. Despite the Registered Dietitian (RD) implementing nutritional interventions, including adding nectar-thickened milk to meals, the resident experienced a significant weight loss of 13% over two weeks. The RD noted the family's request for an appetite stimulant and a diet change, but these were not communicated effectively to the interdisciplinary team (IDT) or documented consistently by nursing staff. Resident #9, diagnosed with alcohol dependence and alcoholic cirrhosis, also experienced significant weight fluctuations. The RD documented a significant weight loss and noted the resident's difficulty in feeding himself. Despite interventions such as fortified foods and an appetite stimulant, the resident's meal intake was inconsistently documented by Certified Nursing Assistants (CNAs), making it difficult to assess the effectiveness of the interventions. The resident's weight continued to decline, and meal refusals were not consistently reported to nursing staff. The Director of Nursing (DON) confirmed the lack of consistent documentation and communication regarding the residents' meal intakes and weight loss. The DON was unaware of the documentation lapses and the failure to capture Resident #9's weight loss on the Roster Matrix. The facility's internal processes, including in-service training for CNAs, were not effectively ensuring compliance with documentation requirements, contributing to the deficiency in monitoring and addressing the residents' nutritional needs.
Failure to Prevent Falls and Provide Adequate Supervision
Penalty
Summary
The facility failed to implement a systemic approach to identify risk factors and provide adequate supervision to prevent avoidable falls with serious injuries for three residents. Resident #10, who had a history of falls and severe cognitive impairment, experienced a fall resulting in a nasal fracture. The fall investigation noted the resident was found face down in the hallway, and the root causes were identified as lack of safety awareness, anxiety, and an unclear walkway. Despite the resident's claim of being pushed, the facility did not document this as a potential cause, and the care plan was only updated to include staff education on keeping walkways clear. Resident #69, with diagnoses including vascular dementia and Alzheimer's disease, sustained a fall resulting in a wrist fracture requiring surgery. The resident was observed wandering unsupervised, and the care plan lacked specific measures for supervision to prevent falls. The family expressed concerns about the lack of supervision and repeated falls, including previous incidents of broken fingers and a hip fracture. The facility's incident log revealed 28 falls in the secured unit, but the care plan did not address the need for adequate supervision. Resident #30, admitted with diagnoses including dementia and repeated falls, experienced multiple falls resulting in injuries, including a subarachnoid hemorrhage. The care plan identified the resident as a fall risk due to wandering and confusion but failed to implement specific interventions for fall prevention. Staff interviews indicated the resident wandered frequently, and there were no fall interventions in place. The Director of Nursing acknowledged the oversight in implementing fall interventions for Resident #30.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a safe and sanitary manner, as observed during a kitchen tour. Unlabeled and undated food items, including meat in a storage bag, were found in the walk-in refrigerator, and the Dietary Manager could not identify the food without labels. Additionally, the dishwasher, originally a high-temperature model, was converted to a low-temperature sanitizing dishwasher, but staff were not trained to use test strips to ensure the appropriate amount of sanitizing agent was present. The dishwasher logs showed no entries for sanitizer levels, only water temperature, and the test strip bottle's label was worn, making it impossible to verify the results. Further observations revealed two large black plastic covers covered in dust and debris stored on the bottom shelf of the steam table, which were used to cover clean plates. The ceiling tiles and air conditioning vents over the food preparation area and clean dish storage were dirty, dusty, and covered in black bio growth. The Maintenance Director, who had been employed for three months, admitted that the vents and tiles were not cleaned monthly as required, due to being too busy. These deficiencies indicate a lack of adherence to the facility's policies on food storage and equipment maintenance, compromising the sanitary conditions necessary for safe food handling.
Deficiency in Activity Program for Memory Care Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the individual needs and preferences of residents in the secured memory care unit. This deficiency was observed in six residents who were not engaged in meaningful activities that aligned with their interests and cognitive abilities. The activity calendar for the unit listed activities such as courtyard time, hydration, and socializing, but these were not effectively implemented. For instance, courtyard time had not occurred in a month due to weather conditions, and the activity calendar was not updated to reflect alternative activities. Several residents, including those with severe cognitive impairments and a history of wandering, were observed without structured activities or staff intervention. Residents were often left sitting in the dining room with the television on, but not engaged in any meaningful way. Some residents were seen wandering the unit without redirection or involvement in activities that could provide cognitive stimulation or social interaction. Staff interviews revealed that the activity aids were not familiar with the residents and struggled to engage them in the planned activities. The facility's failure to provide appropriate activities was further highlighted by family members' concerns and staff admissions. Family members noted the lack of activities and engagement for their loved ones, while staff acknowledged the challenges in implementing the activity calendar due to limited resources and staffing. The Activity Director confirmed that activities were not being conducted as scheduled, particularly for residents who wandered, and there was no specific program to address their needs. This lack of structured activities and engagement contributed to the residents' aimless wandering and lack of stimulation, failing to meet their physical, mental, and psychosocial well-being needs.
Unqualified Activities Director in LTC Facility
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by federal, state, and local standards. The job description for the Director of Therapeutic and Recreational Services specifies that the individual must possess a minimum of a bachelor's degree in therapeutic recreation or equivalent training/experience, along with at least two years of experience in therapeutic recreation. However, upon review, it was found that the current Activities Director, referred to as Staff B, did not have the necessary qualifications or certification in therapeutic activities. The Human Resources Director confirmed that Staff B had been acting as the Activities Director for several months without the required qualifications. Staff B was in training to obtain her certification and was working under the supervision of the Administrator. Despite this, there was no documentation in the employee file to show that Staff B met the requirements for the position. The Administrator also confirmed that Staff B had been in the role for more than six months without the necessary qualifications, following the departure of the previous Activities Director.
Failure to Document CNA Continuing Education
Penalty
Summary
The facility failed to ensure that five Certified Nursing Aides (CNAs), identified as Staff E, N, O, P, and Q, completed the required 12 hours of continuing competency education for the year 2023. This deficiency was identified through staff interviews and a review of employee files, which revealed a lack of documentation confirming the completion of the mandatory training. The CNAs were hired between 2001 and 2021, and the absence of training documentation was confirmed by the Human Resource Director (HRD) and the Assistant Director of Nursing (ADON)/Staffing Coordinator. The HRD acknowledged sending email reminders to CNAs throughout the year to complete their mandatory training via an educational portal. However, there was a miscommunication between the HRD and the ADON regarding the responsibility for monitoring the completion of this training. The HRD believed the ADON was responsible for ensuring compliance, while the ADON assumed it was the HRD's responsibility. This lack of clarity and oversight resulted in the failure to document the completion of the required training for the CNAs in 2023.
Failure to Ensure Dignified Care for Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide care and services with respect and dignity to two cognitively impaired residents in the memory care unit. Resident #69, who was readmitted from an acute care hospital with a fractured and surgically repaired right wrist, was observed without the required dressing or splint, leading to visible swelling and bruising. Despite the resident's discomfort, an LPN administered medication audibly in front of other residents and proceeded to dress the resident's incision in the dining room, causing the resident to become agitated. The LPN blocked the resident's exit and applied an ace wrap to prevent the resident from picking at the sutures, further compromising the resident's dignity. Resident #23, diagnosed with dementia and other mental health disorders, was observed barefoot and later with mismatched socks, wandering the memory care unit without staff intervention. The resident was seen taking food from other residents' plates and personal items from their rooms without redirection from staff. A CNA acknowledged the behavior but did not consistently redirect the resident, and the Director of Nursing confirmed the resident's mismatched socks. These observations indicate a lack of appropriate care and respect for the resident's dignity and personal needs.
Facility Fails to Maintain Safe and Clean Environment in Memory Care Unit
Penalty
Summary
The facility failed to maintain a clean, safe, and comfortable environment in the Memory Care Unit, affecting 9 out of 13 rooms and the dining room. Observations revealed a strong musty odor with a foul smell of urine and feces throughout the unit. Specific issues included a thick black substance on a ceiling tile, missing bathroom mirrors, exposed wires, missing closet doors, broken toilet paper holders, and large holes in walls. Photographic evidence was obtained for many of these deficiencies. Interviews with staff revealed that there had been no Maintenance Director for some time, and the previous director did not address repair needs. The maintenance repair request log showed the last request was dated nearly two months prior to the survey, indicating a lack of timely maintenance actions. The Regional Maintenance Director confirmed the findings and acknowledged the need for addressing the identified issues.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to ensure that a Baseline Care Plan (BCP) was provided to two residents, Resident #4 and Resident #26, upon their admission. Resident #4, who was admitted from an acute care hospital with diagnoses including End Stage Renal Disease and Chronic Diastolic Heart Failure, did not receive a copy of her BCP. The Assistant Minimum Data Set (MDS) Coordinator and Unit Manager confirmed that there was no documentation indicating that Resident #4 or her legal representative received the BCP, which should have included initial goals, a summary of medications, dietary instructions, and services to be administered. Similarly, Resident #26, admitted with conditions such as Chronic Obstructive Pulmonary Disease and Malignant Neoplasm of the Liver, also did not receive a copy of her BCP. The Assistant MDS Coordinator and Unit Manager confirmed the absence of documentation for Resident #26's BCP being provided to her or her representative. The BCP was found unsigned in a binder, indicating it was not reviewed with the resident as required. Interviews with staff, including the Director of Nursing, revealed that the admitting nurse was responsible for completing and reviewing the BCP with the resident at the time of admission. However, this process was not followed for Residents #4 and #26, as confirmed by the lack of documentation and the residents' statements that they did not receive their BCPs or attend an initial care plan meeting.
Failure to Document and Implement Wound Care Orders
Penalty
Summary
The facility failed to implement resident-directed care and treatment per physician order and professional standards of practice for a resident reviewed for wound care. The facility's policy required licensed nurses to complete weekly skin evaluations and document any skin impairments. However, during observations, a resident was found with a bandage on the right wrist that was not documented in the clinical records. The bandage was dated two days prior to the observation, and there was no documentation of a wound care order or progress notes describing the wound's condition or stage of healing. Interviews with staff revealed that the resident had a skin tear on the right wrist, but there was no documentation or physician orders for wound care in the electronic clinical record. The Director of Nursing confirmed the lack of documentation and acknowledged the absence of a wound care order. This oversight in documentation and failure to follow the facility's policy could place the resident at risk for infection or worsening of the wound.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide appropriate dental care and services for a resident with broken teeth. The resident reported not having seen a dental hygienist for several months and was unaware of when she would receive partial dentures to replace her broken teeth, despite being informed by a dentist months prior that she could get them. The resident's medical record indicated she was last seen by a dental hygienist in late 2022, and there was no documentation of routine dental cleaning in 2024. The facility's Social Worker Regional Director (SWRD) confirmed the lack of routine dental care and noted the absence of a full-time Social Service Director (SSD) to coordinate ancillary services, including dental care. The SWRD's review of the resident's medical record and communication with the dentist's office revealed that the resident had been seen by a dentist in April 2024, who documented the resident's interest in tooth extractions and partial dentures. However, there was no evidence that the SSD had followed up with the dentist's office for approval of the extractions and partial dentures. Additionally, there was no documentation of coordination between the SSD, the dentist, and the resident to ensure timely receipt of the partial dentures, as required by the facility's policies and procedures.
Failure to Implement Appropriate Transmission-Based Precautions
Penalty
Summary
The facility failed to implement appropriate transmission-based precautions for a resident diagnosed with influenza, leading to a deficiency in infection prevention and control. The resident, who had a history of diabetes, dementia, schizoaffective disorder, and hypertension, was admitted to the facility and later sent to the hospital for evaluation of chest pain, cough, and elevated blood sugar. Upon returning with a diagnosis of parainfluenza, the resident was placed in a double occupancy room instead of a private room, contrary to the facility's policy and CDC guidelines. The resident was initially placed on contact precautions, and it was not until several days later that droplet precautions were ordered by a physician. Miscommunication among the facility's staff contributed to the failure to implement the correct precautions. The Assistant Director of Nursing/Infection Preventionist acknowledged that the resident should have been placed on droplet precautions and in a private room, but this did not occur due to a breakdown in communication between the Unit Manager and the Director of Nursing. The Director of Nursing was unaware of the need for a private room, and the Regional Nurse provided guidance based on the assumption that the resident was asymptomatic, without referring to the facility's infection control policy. This series of actions and inactions led to the deficiency in managing the resident's transmission-based precautions.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that two residents received showers as scheduled and as requested by their families. Resident #159, who has a history of dementia, muscle weakness, dysphagia, and difficulty walking, was admitted to the facility and required partial assistance for showering. Despite a written grievance from her granddaughter on 3/12/24, stating that Resident #159 had not received a shower since admission, the facility only documented one shower for her in March 2024. The Director of Nursing acknowledged that if the showers were not documented, they were not done, indicating a failure in both providing and documenting the necessary care. Similarly, Resident #7, who has a history of muscle weakness, chronic pain, difficulty walking, unsteadiness, abnormalities with gait and mobility, and repeated falls, also required partial assistance for bathing. The facility's documentation showed that Resident #7 had only one shower in March 2024. The resident confirmed that he had not received a shower for a week prior to the survey date. This indicates a consistent failure by the facility to provide and document the required showers for residents, leading to deficiencies in their care.
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Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
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