Aventura At The Bay
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Petersburg, Florida.
- Location
- 10300 4th St N, Saint Petersburg, Florida 33716
- CMS Provider Number
- 105688
- Inspections on file
- 32
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 33
Citation history
Health deficiencies cited at Aventura At The Bay during CMS and state inspections, most recent first.
A resident with a strict pain management regimen did not receive scheduled hydrocodone-acetaminophen doses on two occasions because the nurse documented the resident as sleeping and did not attempt to wake her, despite the resident's preference to be woken for medication. The missed doses were not communicated to the physician or the resident's representative, and there was no documentation in the care plan or progress notes regarding the missed medications.
A resident with a strict pain management regimen did not receive scheduled hydrocodone doses on two occasions because the nurse documented the resident as sleeping and did not attempt to wake her or notify the physician or family representative. Staff interviews and record reviews confirmed that facility policy requires attempts to wake residents for scheduled medications and prompt notification of missed doses, but these steps were not followed or documented.
Several residents with documented food allergies, intolerances, and preferences were served meals that did not accommodate their needs, resulting in one resident experiencing an allergic reaction requiring epinephrine. Other residents received food in forms they could not safely eat or with ingredients they had specifically requested to avoid, despite these requirements being documented on meal tickets and in care plans. Staff interviews and committee minutes revealed ongoing issues with meal ticket accuracy and communication between dietary and nursing staff.
Two residents experienced major injuries due to repeated falls and inadequate supervision, with one sustaining a thumb and rib fracture and another suffering a femur fracture. Despite known high fall risk and total care needs, care plans were not consistently updated after incidents, and staff interviews revealed gaps in awareness and documentation. The facility did not maintain a hazard-free environment or provide adequate supervision as required by policy.
The facility did not maintain the area around the outside trash compactor free of refuse, with observations showing scattered trash such as used gloves, opened trash bags, and food containers on the ground. The Maintenance Director confirmed ongoing issues with trash from multiple departments and wildlife interference, and there was no documentation of regular monitoring or a policy addressing cleaning of the compactor's surroundings.
The facility did not ensure that residents with intact cognition were properly informed about the optional nature of the binding arbitration agreement during admission. Several residents signed the agreement without clear understanding that it was not required, and staff could not provide documentation or policy confirming residents' rights to refuse or contact state personnel.
The facility's arbitration agreement did not allow for the mutual selection of a neutral arbitrator, instead specifying that arbitration would be conducted by a predetermined entity or one chosen solely by the facility, without input from residents. This was confirmed through record review and staff interviews, with staff acknowledging the lack of resident choice and the absence of a related policy.
Multiple failures in infection prevention and control were observed, including staff entering rooms on special contact/droplet precautions without proper PPE, missing or incorrect isolation signage, and inconsistent hand hygiene practices. Residents on precautions were seen in hallways without masks, and shared medical equipment was not cleaned between uses. Additional issues included improper catheter bag placement and staff with artificial nails, all contrary to facility policy and care plans.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Surveyors found widespread deficiencies in the cleanliness and maintenance of resident rooms, bathrooms, and equipment, including water leaks, bio growth, stained fixtures, and non-cleanable surfaces. Staff interviews revealed confusion about reporting and resolving these issues, and maintenance logs were lacking. Facility policies for cleaning and HVAC maintenance were not consistently followed, resulting in ongoing environmental concerns.
The facility failed to ensure safe and appropriate respiratory care by not administering oxygen therapy according to physician orders for four residents. Residents were observed receiving oxygen at incorrect flow rates, with staff unable to locate or confirm the correct orders, and care plans containing conflicting information. Staff interviews revealed uncertainty about proper oxygen settings and order documentation.
Surveyors identified multiple deficiencies in medication management, including prescription creams and medications left unsecured in resident rooms, an unlocked office with accessible medications, and medication carts containing personal items, loose pills, and undated glucose test strips. Staff and the DON confirmed that these practices did not follow facility policy, and medications were also improperly disposed of in a trash can.
Multiple residents reported not being routinely offered evening snacks, with some staff stating snacks were unavailable or only providing them upon request. Only one CNA was identified as regularly offering snacks, and the facility's meal schedule resulted in a 15-hour gap between dinner and breakfast. Staff interviews confirmed snacks were not proactively offered to all residents, and a resident with diabetes emphasized the need for an evening snack.
Multiple residents were found to have non-functioning or inaccessible call lights, with some call lights not working upon admission and others placed out of reach, such as in closed dresser drawers. Staff interviews revealed inconsistent practices for reporting and ensuring call light functionality, and there was no formal policy in place. Maintenance was not always notified of issues, and routine checks were insufficient to prevent these deficiencies.
The facility did not consistently document or resolve grievances raised by residents, family members, or through committee meetings, particularly regarding meal preferences, staff conduct, and care concerns. Multiple residents reported that their complaints were not addressed or followed up on, and staff interviews confirmed that grievance documentation and tracking were incomplete or missing for several months.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
Staff did not ensure that all residents seated at the same table were served meals at the same time, resulting in some residents waiting without food or drink while others ate. CNAs and an RN confirmed that trays were distributed in room order rather than by table, contrary to facility policy and expectations for resident dignity during dining.
A resident with multiple mental health diagnoses, including mood disorder, dementia, and bipolar disorder, was not properly assessed through the PASRR process, as the facility failed to submit a required Level II evaluation. The ADON confirmed that only limited audits were performed and demonstrated a lack of understanding regarding which diagnoses necessitate Level II submission. The facility also lacked a formal PASRR policy.
Two residents did not receive catheter care as required, with one resident's suprapubic catheter site left uncleaned and dressing unchanged for several days, and another resident's catheter care not documented on multiple shifts. Staff interviews confirmed lapses in care and documentation, and one resident developed a UTI. Facility policy required catheter care every shift and proper documentation, which was not followed.
A resident with multiple chronic conditions and under hospice care experienced severe, ongoing pain that was not managed in a timely manner. Despite repeated reports of high pain levels and a new order for Baclofen, staff failed to administer the medication promptly due to confusion about its availability and delays in obtaining it from the pharmacy or emergency drug kit. The DON acknowledged the resident should have received the medication as ordered.
Two residents were not offered the COVID-19 vaccine upon admission, as required by facility policy. Both individuals were later diagnosed with COVID-19 after being sent to the Emergency Department, and their medical records lacked documentation of vaccine consent or refusal. The Infection Preventionist confirmed the omission, noting it should have been part of the admission process.
The facility did not provide enough nursing staff to meet resident needs, as shown by multiple residents experiencing long wait times for assistance, including help with toileting and mobility. Residents with significant medical conditions were left unattended, and staff interviews confirmed ongoing staffing shortages and unpredictable assignments. Resident Council meeting minutes documented repeated concerns about delayed call light responses, and the staffing coordinator admitted that required staffing levels were not always met, especially on weekends.
The facility failed to implement adequate policies and procedures to prevent abuse, neglect, and exploitation of residents, as well as misappropriation of resident property. Employee files for six staff members, including LPNs, RNs, and CNAs, lacked timely addition to the Background Clearinghouse and did not include reference checks for prior employment. The facility's policy did not provide procedures for employee screening or employment verification, contributing to the deficiency.
A resident's preference for female caregivers was not honored, despite being documented in her care plan. The resident, who was mentally intact, had requested female caregivers for incontinence care, but male caregivers were assigned on several occasions. The facility's leadership acknowledged the issue and confirmed the availability of female caregivers during those times.
The facility failed to address grievances from two residents regarding delayed call light responses, improper meal setup, and medication issues. Despite filing grievances, the residents did not receive feedback or resolution, and the facility's grievance log lacked documentation. The facility's grievance policy was not followed, leading to unresolved concerns and a deficiency in honoring residents' rights.
A resident with pressure ulcers and paraplegia did not receive timely repositioning and incontinence care, leading to skin irritation and emotional distress. Additionally, a CNA conducted a lift transfer without assistance, against protocol. Another resident's call light was out of reach, preventing them from requesting assistance. Medication administration was also deficient, with missed doses due to untimely reordering.
The facility failed to provide sufficient nursing staff, resulting in inadequate care for residents. Observations revealed unchanged bandages, delayed call light responses, and insufficient assistance with ADLs and meals. Staff shortages were evident, with reports of call-offs and no-shows, leading to neglect of resident care and an Immediate Jeopardy determination.
The facility failed to update its emergency plan and secure safe evacuation locations during two hurricanes, leading to chaotic and unsafe conditions for residents. The Nursing Home Administrator did not secure an alternative location after the termination of an evacuation agreement with a local church. During evacuations, residents were moved to unsuitable locations, resulting in overcrowding, lack of supplies, and safety risks. Local authorities had to intervene to relocate residents to safer locations. Staff and residents reported disorganization and distress during the evacuations.
The facility's failure to update its emergency plan and secure an approved evacuation location led to a chaotic and unsafe evacuation during Hurricane [NAME]. Residents were moved to an unapproved church location, deemed unsafe by local authorities, resulting in the relocation to a county shelter. Two residents suffered harm due to lack of supplies and supervision. The governing body was unaware of the terminated evacuation agreement, and the facility's emergency plan was outdated, leading to immediate jeopardy for residents.
A LTC facility failed to protect residents from neglect, resulting in multiple incidents of harm. A resident with dementia suffered a hip fracture during a transfer, with inadequate investigation and communication. Another resident fell from bed due to improper handling by a CNA, leading to significant injuries. A third resident fell during an evacuation due to lack of supervision and organization. The facility's care plans lacked specific assistance requirements, contributing to these incidents.
A facility failed to provide a hazard-free environment and adequate supervision, resulting in falls and injuries for three residents. One resident with Alzheimer's disease sustained a hip fracture during a transfer, while another with a stroke fell from bed due to inadequate assistance. A third resident fell during an evacuation due to lack of supervision and assistive devices. The facility's care plans lacked clear directives, contributing to these incidents.
The facility failed to maintain a safe, clean, and homelike environment, with deficiencies observed across all resident units. Issues included locked bathroom doors, bio-growth on ceilings, dirty air conditioning vents, and electrical hazards. Some common areas had offensive odors, and maintenance problems persisted despite an electronic work order system. The Director of Maintenance acknowledged the issues, highlighting a disconnect between facility policies and actual conditions.
The facility failed to report and investigate alleged abuse or neglect for three residents. One resident suffered a fracture during a transfer, which was not reported as abuse or neglect. Another resident fell from an air mattress, resulting in a head injury, due to unclear assistance directives. A third resident fell during an evacuation, resulting in a fracture, with no post-storm assessment conducted.
The facility failed to provide adequate assistance with ADLs for several residents, leading to deficiencies in care. A resident was observed with food on his face and reported not having received a shower or bed bath for about two weeks. Another resident reported delays in receiving daily care and infrequent showers. A family member reported that the facility was often short-staffed, resulting in missed showers for a resident. Additionally, a resident was observed with her breakfast tray out of reach and no call bell accessible, and during a lunch observation, residents were left unattended in the dining room, with one resident calling for assistance and not receiving help until surveyors intervened.
The facility failed to provide proper wound care for four residents, leading to complications and dissatisfaction. A resident had an unchanged bandage for weeks, another had multiple wounds with no dressing changes for 10 days, and a third missed wound care during a hurricane evacuation, resulting in hospitalization. A fourth resident had a bandage that was not changed since admission, with no wound care orders in place. Staff were unaware of these issues, indicating a lack of adherence to the facility's wound care policy.
A facility failed to administer medications as per physician orders for three residents, leading to a deficiency in pharmaceutical services. A resident with chronic pain missed doses of Flomax and Lyrica without documentation. Another resident with Type II Diabetes and atrial fibrillation missed several medications due to pharmacy orders, lacking documentation and physician notification. A third resident with epilepsy and chronic pain experienced missed doses of Keppra and Lyrica, with delays attributed to late prescription requests. The DON cited issues with agency nurses and system integration with the pharmacy.
The facility failed to provide timely laboratory services for three residents, resulting in missed or delayed lab results. A resident with multiple health issues had lab tests ordered but not completed, leading to delayed abnormal results. Another resident with symptoms of a urinary tract infection had multiple orders for urinalysis, but results were only obtained after significant delays. A third resident experienced issues with urine sample collection, resulting in delayed lab results showing bacterial presence. Staff interviews revealed a lack of awareness of these issues, and the laboratory confirmed missing orders.
A resident with an ulcer on her left foot had an ultrasound revealing critical findings, including occluded arteries. The LPN documented the results but did not recall discussing them with anyone. The PCP was informed, but the wound care provider who ordered the test was not notified. The facility's system failed to flag the results as critical, leading to a lack of follow-up and delayed care.
The facility failed to implement effective infection control practices, with staff neglecting hand hygiene and PPE protocols, and improper management of soiled linens. Observations showed staff entering and exiting rooms without washing hands, used gloves discarded on floors, and PPE carts misused. Housekeeping practices were inadequate, with soiled linens improperly stored and carts in dining areas during meals. Staff interviews revealed a lack of understanding of contact and enhanced barrier precautions, confirmed by the ADON/IP.
The facility failed to properly store medications, with unsecured medication carts and medications left unattended in resident areas. Observations revealed unlocked carts, medications on bedside tables, and personal items stored with medications. Staff admitted to these practices, acknowledging the need for secure storage as per facility policy.
The facility failed to provide sufficient nursing staff, resulting in delayed responses to call lights. Residents reported waiting 30-45 minutes for assistance, and staff interviews confirmed they were overwhelmed with the number of residents they had to care for. Observations showed call lights being ignored, even when residents were in urgent need of help.
The facility failed to maintain a clean and comfortable environment in two hallways, with issues such as soiled toilets, dirty floors, missing tiles, peeling paint, and black/brown bio-growth. The Maintenance Director was unaware of these issues and confirmed there was no policy in place to address the environment.
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of live spiders and roaches in shared shower rooms. Staff confirmed the presence of pests and reported that current pest control measures were ineffective. Despite regular pest control visits, the problem persisted, and maintenance staff were unaware of the severity of the issue.
The facility failed to revise a care plan to reflect the nonuse of a secure door safety banner stop sign for a resident. Despite the care plan indicating the need for a stop sign due to the resident's risk for abuse and neglect, staff interviews and observations confirmed that the stop sign was never used. The RN/Director of MDS was unaware of the reason for this intervention and found no assessments to support it.
The facility failed to provide adequate personal grooming for two residents who were dependent on staff for ADLs. One resident was observed with facial hair above her lip, and another had dark brown material underneath her nails on multiple occasions. Staff interviews and lack of documentation indicated inconsistent adherence to grooming schedules.
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically related to the labeling of dressings. Observations revealed that the resident had a large white dressing on his left calf that was not labeled with staff initials or a date, contrary to the physician's orders. Interviews with staff confirmed that dressings should be dated and initialed, but the facility did not provide a policy related to the standards of practice for labeling wounds.
A resident with a laryngectomy tube faced issues with inadequate tube length, lack of necessary supplies, and canceled ENT appointments due to transportation and insurance problems. The facility failed to assess the resident's competency in self-care and did not provide appropriate materials for cleaning the tube.
The facility failed to ensure a licensed pharmacist performed a monthly drug regimen review for a resident with multiple diagnoses, resulting in a lack of documented recommendations and actions by the attending physician or DON.
Failure to Notify Physician of Missed Scheduled Pain Medication Doses
Penalty
Summary
The facility failed to ensure that a physician was notified of missed doses of scheduled pain medication for one resident. The resident, who had diagnoses including seizures, muscle weakness, anxiety disorder, major depressive disorder, and post-concussional syndrome, was on a strict pain management regimen with hydrocodone-acetaminophen scheduled every four hours. On two separate nights, the resident did not receive the 2:00 AM dose of pain medication because the nurse documented the resident as sleeping and did not attempt to wake her, despite the resident's stated preference to be woken for scheduled doses. There was no documentation in the care plan indicating the resident refused medications or did not want to be woken up, and the resident consistently expressed the importance of maintaining the medication schedule to prevent pain. Record review and staff interviews confirmed that the missed doses were not communicated to the resident's physician or representative, and there was no documentation in the progress notes regarding the missed medications. Facility staff, including the LPN, Unit Manager, and DON, acknowledged that the expectation was to attempt to wake residents for scheduled medications and to document any refusals or missed doses. The facility's pain management guidelines also required collaboration with the physician and documentation of interventions to manage pain, which was not followed in this instance.
Failure to Administer Scheduled Pain Medication and Notify Physician/Family
Penalty
Summary
A deficiency occurred when the facility failed to ensure that scheduled pain medications were administered as ordered and that appropriate notifications were made to the physician and family representative for a resident requiring consistent pain management. The resident, who had diagnoses including seizures, muscle weakness, anxiety disorder, major depressive disorder, and post-concussional syndrome, was on a strict regimen of hydrocodone-acetaminophen every four hours to prevent pain, as per physician orders. On two occasions, the resident did not receive the scheduled 2:00 AM dose because the nurse documented the resident as sleeping and did not attempt to wake her or provide the opportunity to refuse the medication. Interviews with staff, including the Unit Manager, LPN, and DON, confirmed that the facility's policy requires staff to attempt to wake residents for scheduled medications and to notify the physician and family representative if a dose is missed or refused. However, there was no documentation of any such attempts or notifications for the missed doses. The resident herself reported waking up in pain and expressed the importance of maintaining her medication schedule to prevent breakthrough pain. A review of the resident's care plan and progress notes revealed no documentation regarding medication refusals or instructions not to be woken for medications. The facility's pain management guidelines and medication administration policy both emphasize the need for consistent pain management, proper documentation, and communication with the physician and family representative when scheduled medications are missed. These procedures were not followed in this case, resulting in the identified deficiency.
Failure to Honor Food Allergies, Intolerances, and Preferences
Penalty
Summary
The facility failed to ensure that food allergies, intolerances, and preferences were honored for four residents out of six sampled for dietary concerns. One resident, who had documented allergies to fish, seafood, and tomatoes, was served a fish sandwich and stewed tomatoes despite these allergies being listed in both hospital and provider records available in the facility. The resident experienced an allergic reaction after consuming the fish sandwich, requiring administration of an epinephrine auto-injector. Staff interviews revealed a lack of awareness and communication regarding the resident's allergies, and the Director of Nursing acknowledged that the allergy information was present in the medical record but not acted upon. Another resident with chewing and swallowing difficulties, as well as a broken wrist, was repeatedly served food that was not cut into bite-sized pieces as required by their care plan and tray card instructions. The resident reported difficulty eating and swallowing the food provided and stated that requests for dietary consultation were not addressed. The Registered Dietician confirmed the need for a mechanically altered diet and that food should be cut into small pieces, but the resident continued to receive whole pieces of meat. Two additional residents reported that their food preferences and dislikes, such as avoiding gravy, were not honored, with meal tickets indicating dislikes that were not followed by dietary staff. Both residents stated that they had informed staff of their preferences, but the issues persisted. Food committee meeting minutes and staff interviews confirmed ongoing problems with meal ticket accuracy and repeated errors in honoring resident preferences and allergies, despite in-services and audits. Facility policies required identification and accommodation of allergies and preferences, but these were not consistently implemented.
Failure to Prevent Accidents and Maintain Hazard-Free Environment
Penalty
Summary
The facility failed to ensure adequate supervision and interventions to prevent major injuries for two residents and to maintain a hazard-free environment for another, as evidenced by multiple falls and injuries. One resident with a history of Parkinson’s disease, dementia, and high fall risk experienced repeated falls, some resulting in injuries such as a laceration above the eye, a thumb fracture, and rib fractures. Despite these incidents, care plan interventions were often repeated rather than updated with new strategies, and there was a lack of timely documentation and interdisciplinary team (IDT) review following several falls. Staff interviews revealed inconsistent knowledge of the resident’s care plan and fall history, and the care plan was not always updated after each incident as required by facility policy. Another resident, who was non-verbal, bed-bound, and dependent for all care due to a traumatic brain injury and spastic hemiplegia, developed significant bruising and swelling to the left leg. The injury was initially attributed to spasticity, but subsequent assessments and imaging revealed a displaced femur fracture. Staff interviews indicated a lack of awareness regarding how the injury occurred, with some staff recalling rumors of a fall or transfer incident but no direct observation or documentation. The facility’s investigation into the injury was inconclusive, and there was no clear evidence of adequate supervision or environmental safety measures to prevent such an injury in a dependent resident. The facility’s policies required comprehensive accident and incident reporting, timely investigation, and care plan updates following accidents or injuries. However, the report documents lapses in these processes, including delayed or incomplete investigations, repeated rather than revised interventions, and insufficient staff communication regarding resident incidents. These failures contributed to the residents experiencing preventable injuries and an environment that was not consistently free from accident hazards.
Improper Disposal and Maintenance of Trash Compactor Area
Penalty
Summary
The facility failed to ensure the area surrounding the large outside trash compactor was free from refuse and trash debris during the survey. Observations revealed numerous pieces of trash, including used plastic gloves, full bags of opened trash, soiled Styrofoam containers, plastic straws, and crumpled napkins and paper scattered on the ground around the compactor. The compactor door was closed, but debris was present on all sides. The Maintenance Director acknowledged ongoing issues with trash accumulation in the area, noting that trash comes from all departments and that staff are educated on proper disposal. Additionally, the presence of ducks in the area was mentioned as a contributing factor. There was no documentation of continued monitoring of the compactor area, and the facility's trash compactor policy did not specify routine cleaning or maintenance of the surrounding area.
Failure to Ensure Residents' Informed Choice Regarding Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents or their representatives were properly informed about the binding arbitration agreement, including their right to refuse to sign and that signing was not a condition of admission or continued care. Record reviews and interviews revealed that three residents with intact cognition signed the arbitration agreement as part of their admission paperwork. However, these residents either did not recall being informed that the agreement was optional or were unsure if the documents were mandatory. One resident specifically stated not being in the right frame of mind at the time of signing due to illness, and another was uncertain if the documents were optional. Interviews with the admissions staff indicated that while they verbally explained the arbitration agreement and stated it was not required, the agreement itself did not clearly indicate that signing was optional or that residents could still contact state personnel. Additionally, the admissions staff and the Nursing Home Administrator were unable to locate a policy or procedure regarding the signing of the arbitration agreement, and the NHA had not reviewed the agreement. This lack of clear documentation and policy contributed to the deficiency in ensuring residents' informed choice regarding arbitration agreements.
Arbitration Agreement Lacks Mutual Selection of Neutral Arbitrator
Penalty
Summary
The facility failed to ensure that its arbitration agreement allowed for the selection of a neutral arbitrator mutually agreed upon by both parties, as required. Record review showed that the agreement specified arbitration would be conducted by the American Health Lawyers Association (AHLA) through its Alternative Dispute Resolution (ADR) service, and if unavailable, the facility would unilaterally select another ADR entity. This process did not provide residents with a choice in the selection of the arbitrator. The agreement was signed by three residents. During interviews, the Admission Coordinator acknowledged that the agreement did not appear to give residents a choice in arbitration, and the Nursing Home Administrator (NHA) indicated unfamiliarity with the agreement and was unable to provide a relevant policy or procedure.
Infection Control Program Deficiencies: PPE, Isolation, and Hand Hygiene Failures
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by multiple observed deficiencies in the use of personal protective equipment (PPE), posting and adherence to isolation precautions, and hand hygiene practices. Staff were observed entering rooms requiring special contact/droplet precautions without donning appropriate PPE, and residents on such precautions were seen moving freely in hallways without masks. Interviews with staff revealed inconsistent understanding of when PPE was required, with some staff only wearing PPE during direct care and others unsure of the correct precautions. In several instances, isolation signage was missing from doors of rooms with residents positive for COVID-19, and staff were unaware of the necessary precautions until prompted by surveyors. Hand hygiene practices were also not consistently followed. Staff were observed administering injections, handling medication carts, and performing blood glucose checks without performing hand hygiene between tasks or between resident contacts. Shared medical equipment, such as blood pressure cuffs and glucose monitoring strip bottles, were not cleaned between uses or after being in resident rooms, and respiratory masks were left uncovered in resident rooms. Staff interviews confirmed that proper hand hygiene and equipment cleaning protocols were not always followed, and the DON acknowledged that these practices were not in line with facility policy. Additional deficiencies included improper management of indwelling urinary catheters, with a resident's catheter bag observed clipped to a garbage can and touching the floor, contrary to physician orders and care plan interventions. Staff were also observed with artificial nails, which is against facility policy for direct care staff. Housekeeping staff demonstrated inconsistent understanding of PPE requirements for different types of precautions, and language barriers further complicated adherence to protocols. Review of care plans and policies confirmed that the observed practices did not align with established infection control procedures.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Maintain Clean, Safe, and Homelike Resident Environment
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a clean, safe, and homelike environment for residents across all units and over several days. Resident rooms and bathrooms were found with significant cleanliness and maintenance issues, including waterlogged towels used to address leaks, bio growth on shower tiles and grouting, stained and oxidized bathroom fixtures, and non-cleanable surfaces such as torn fall mats and over-bed tables. Equipment such as shower chairs and fabric chairs were also found to be in poor condition, with visible bio growth and surfaces that could not be adequately cleaned. In several instances, resident areas were cluttered with unused wheelchairs and mechanical lifts, blocking access to common spaces. Interviews with staff revealed a lack of clarity and accountability regarding the reporting and resolution of maintenance and cleanliness issues. The unit manager confirmed that all staff are responsible for observing and reporting such concerns, but was unaware of the specific deficiencies identified by surveyors. The maintenance director stated that work orders are addressed by priority but acknowledged that neither he nor his staff conduct daily room checks, relying instead on reports from other staff. There was also confusion regarding departmental responsibilities for equipment maintenance, such as wheelchairs and fall mats, and no maintenance logs were kept for certain items. Additional observations included malfunctioning air conditioning units that were loud and disruptive to residents, water leaks resulting in stained ceiling tiles and puddles in hallways, and privacy curtains and assist rails with visible brownish substances. Facility records showed that some maintenance issues, such as water leaks, were documented in work orders, but there was no documentation regarding the loud air conditioning unit. Facility policies required regular cleaning and maintenance of resident rooms and HVAC systems, but these procedures were not consistently followed, as evidenced by the ongoing issues observed during the survey.
Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
The facility failed to ensure that oxygen therapy was administered according to physician orders for four residents. In multiple instances, residents were observed receiving oxygen at flow rates different from those prescribed. For example, one resident with COPD and a physician order for 2 L/min via nasal cannula was observed receiving oxygen at 4 L/min and later at 2.75 L/min. The resident’s care plan and orders specified the required oxygen settings, but these were not followed during observations. The Director of Nursing confirmed that the oxygen concentrator was not set to the ordered rate and was unsure if staff knew how to read the flowmeter. Another resident was observed receiving 2.5 L/min of oxygen, but the active physician order did not specify a flow rate. The care plan contained conflicting interventions, listing different flow rates (2 L/min, 2.5 L/min, and 4 L/min), and staff were unable to locate the correct order in the system. Staff interviews revealed uncertainty about the correct oxygen parameters, and a new order was only entered after the deficiency was identified. In a separate case, a resident with a tracheostomy was receiving 3 L/min of humidified oxygen, but the physician order specified 28% humidified oxygen without a corresponding liter flow. Staff were unable to locate the specific order for the oxygen flow rate and expressed uncertainty about the correct setting. Additionally, another resident was observed receiving 1.5 L/min of oxygen, while the physician order had previously specified 4 L/min as needed and 2 L/min for ambulation, both of which had been discontinued. The care plan referenced following orders for oxygen therapy, but the observed administration did not match any active order. The facility’s policy on oxygen administration outlined procedures for infection control and documentation but did not address the discrepancies in following physician orders for oxygen flow rates.
Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
Multiple deficiencies were identified regarding the storage, labeling, and security of medications and biologicals. Observations revealed that prescription creams and medications were left out in resident rooms, including a tube of Triamcinolone Cream on a bathroom counter and Ammonium Lactate cream on a bedside table, along with medicine cups containing unidentified creams. Additionally, an unlocked office labeled 'Nurse Supervisor' was found with prescription medications, iodoform packing, and wound cleanser left unsecured and accessible, with the door open and no staff present on multiple occasions. Audits of medication carts uncovered further issues, such as narcotics stored correctly in a separate locked compartment, but with personal items like hearing aids, chargers, money, and a cell phone stored alongside medications. Loose medication capsules and medication cups with unidentified pills were found in drawers, and staff were unable to identify or account for these medications. Opened glucose test strips were found undated in multiple carts, and staff acknowledged that these should be dated upon opening. In one instance, a medication refused by a resident was improperly disposed of in a trash can instead of following the facility's disposal protocol. Interviews with staff and the DON confirmed that these practices were not in accordance with facility policy or professional standards. Staff admitted to not knowing the origin or intended use of some medications found, and the DON acknowledged that medications and personal items should not be stored together, and that medications should not be left unsecured or improperly disposed of. The facility's policy requires all medications and biologicals to be stored in locked compartments and for medication storage areas to be maintained in a clean, safe, and sanitary manner, which was not consistently followed.
Failure to Offer Evening Snacks to Residents
Penalty
Summary
The facility failed to provide nourishing evening snacks to seven residents who were sampled for dining, as evidenced by multiple resident interviews and record reviews. Several residents reported that evening snacks were not routinely offered, and when requested, staff sometimes stated that snacks were unavailable or had run out. Only one CNA was identified as regularly offering snacks, typically cookies, during his shifts, while other staff did not proactively offer snacks to residents. Residents expressed that the lack of evening snacks was particularly concerning due to the significant time gap between dinner and breakfast, which was confirmed to be approximately 15 hours according to the facility's meal delivery schedule. Staff interviews revealed that while snacks were available on the units, they were only provided to residents who specifically requested them or had a physician's order, rather than being offered to all residents. The Dietary Manager confirmed that snacks were delivered to the units but was unaware if staff were distributing them to residents. Facility policy states that the time between the evening meal and breakfast should not exceed 14 hours unless a substantial snack is served at bedtime, yet this was not consistently practiced. One resident with diabetes specifically noted the need for an evening snack, highlighting the importance of this service for residents with medical needs.
Failure to Ensure Functioning and Accessible Call Light System
Penalty
Summary
The facility failed to ensure that a functioning call light system was available and accessible for multiple residents. Several residents reported or were observed to have non-functioning call lights in their rooms and bathrooms. One resident stated that upon admission, the call light did not work and it was not fixed until the following day, during which time no alternative means to summon staff was provided. Another resident reported a non-working call light, which was confirmed by staff, and there was no indication that maintenance had been notified in a timely manner. Observations and interviews confirmed that call lights in several rooms were either not functioning or not present, and in one case, a call light was found out of reach in a closed dresser drawer, making it inaccessible to the resident. Staff interviews revealed inconsistent practices regarding the placement and reporting of non-functioning call lights. Some staff stated that call lights should be within reach of residents and that maintenance should be notified through a paper form or work order system if a call light was not working. However, there was no evidence of a formal policy on call light functionality, and maintenance staff indicated that they were not always notified of issues. The maintenance director reported that monthly checks were performed in a limited number of rooms and that pre-admission checklists included call light functionality, but these measures did not prevent the deficiencies observed. Multiple staff members confirmed that call lights should not be placed in drawers or out of reach, and that non-functioning call lights should be reported immediately. Despite these expectations, several rooms were found to have call lights that were either not working or not accessible to residents. The lack of a consistent system for ensuring call light functionality and accessibility contributed to the deficiency, as evidenced by the observations, interviews, and record reviews documented in the report.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were properly documented and resolved, as required by policy and regulation. Multiple residents reported ongoing issues with meal choices, meal ticket accuracy, and the honoring of food preferences and dislikes. For example, one resident repeatedly received meals with items listed as dislikes on her meal ticket, such as gravy, and did not receive requested alternatives like a chef salad, despite having standing orders. Another resident with a history of ulcers received tomatoes on her tray, which she had specifically requested to avoid. These concerns were voiced to staff but were not consistently documented as grievances or followed up with appropriate dietary consultations. Resident Council and Food Committee meetings revealed recurring concerns about meal ticket errors and other issues, such as staff using personal phones during care, call lights not being answered, and cleanliness problems. Despite these issues being raised repeatedly in meetings and committee minutes, there was a lack of corresponding documentation in the grievance log for several months. Residents and their representatives also reported that grievances were not being followed up on or communicated back to them, and that the process for addressing grievances was unclear or inconsistently applied. In some cases, grievances submitted by family members or surrogates were not fully documented or tracked, and some issues were marked as resolved without evidence of comprehensive follow-up. Interviews with facility staff, including the Nursing Home Administrator, Certified Dietary Manager, and Social Services staff, confirmed gaps in grievance documentation and tracking. Staff acknowledged that grievances were not always logged, especially those arising from committee meetings or voiced informally by residents. The facility's own policy requires prompt documentation, investigation, and written resolution of all grievances, but records showed that this process was not consistently followed. As a result, residents' rights to voice grievances without discrimination or reprisal, and to have those grievances promptly addressed, were not upheld.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to maintain resident dignity during meal service in one of four observed dining rooms. Observations revealed that residents seated at the same table were not served their meals simultaneously. On one occasion, four out of six residents at a table were eating while two others had no food or drink, and a CNA was present but not actively assisting. Staff interviews confirmed that trays were distributed in room order rather than ensuring all residents at a table were served at the same time, despite staff acknowledging that simultaneous service was the expectation. Further observation showed a similar pattern, with some residents having finished their meals while others waited without food or drink. Staff again indicated that the current practice was to serve trays in room order, not by table, which resulted in residents at the same table experiencing delays in meal service. Review of facility policies emphasized the importance of preparing the environment to make mealtime pleasant and upholding resident rights to dignity and respect, which were not followed in these instances.
Failure to Complete Accurate PASRR Assessments and Submit Required Level II Evaluations
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASRR) assessments were accurate and that a Level II PASRR was submitted for one resident with relevant mental health diagnoses. Record review showed that the resident was admitted with diagnoses including mood disorder, insomnia, dementia, and bipolar disorder. The Level I PASRR indicated no suspicion or diagnosis of Serious Mental Illness or Intellectual Disability, and a Level II PASRR evaluation was not completed, despite the resident's diagnoses. During an interview, the Assistant Director of Nursing (ADON) acknowledged that PASRR audits were being conducted but stated that outside of these audits, no further action had been taken for existing residents. The ADON also indicated a misunderstanding of which diagnoses require Level II submission, as she did not submit for bipolar disorder. Additionally, the facility did not have a PASRR policy in place.
Failure to Provide and Document Catheter Care for Two Residents
Penalty
Summary
The facility failed to provide adequate catheter care for two residents, resulting in deficiencies related to catheter site hygiene and documentation. One resident with a suprapubic catheter reported that the site had not been cleaned or the dressing changed for three days, and this lack of care persisted even after the concern was voiced to staff. The resident, who was dependent for all activities of daily living due to paraplegia and had multiple comorbidities including neurogenic bladder and chronic kidney disease, stated that catheter care had not been performed correctly since a nurse who previously provided her care resigned. Staff interviews confirmed that the catheter site had not been cleaned or the dressing changed as required during the previous shift, and that CNAs were only responsible for emptying the catheter bag, not for site care. Another resident with an indwelling urinary catheter reported that catheter care was not consistently performed every shift as ordered. Review of the treatment administration record revealed multiple shifts where catheter care was not documented as completed. This resident was cognitively intact and had an order for catheter care every shift with soap and water. Laboratory results indicated that the resident developed a urinary tract infection, and an antibiotic was subsequently ordered. Facility policy required catheter care to be performed every shift and documented accordingly, including assessment data and any problems noted. The policy also outlined the importance of maintaining aseptic technique, securing the catheter, and monitoring for signs of infection. The failure to provide and document catheter care as ordered and per policy led to the identified deficiencies for both residents.
Failure to Provide Timely Pain Management for Resident on Hospice
Penalty
Summary
A resident with multiple diagnoses, including pulmonary fibrosis, diabetes, atrial fibrillation, hyperlipidemia, hypertension, and end stage renal disease, experienced ongoing and significant back pain while under hospice care. Despite repeated reports of severe pain and visible signs of discomfort, the resident did not receive timely administration of prescribed pain medication. The resident reported inadequate pain relief and stated that staff could not provide additional medication while waiting for hospice intervention. Pain assessments documented high pain levels, with scores reaching up to 9/10 on several occasions. A new order for Baclofen 10 mg was prescribed by hospice, but the medication was not administered until nearly two days after the order was placed. Staff interviews revealed confusion regarding the availability of the medication, with some staff unaware of its location and others indicating it had not arrived from the pharmacy. The unit manager and LPNs discussed accessing the medication from the emergency drug kit, but delays persisted. The Director of Nursing confirmed that the resident should have received the medication when ordered and acknowledged that staff could have contacted the medical director for an alternative order while waiting for hospice. The facility was unable to provide a medication administration policy when requested.
Failure to Offer COVID-19 Vaccine Upon Admission
Penalty
Summary
The facility failed to ensure that two residents were offered the COVID-19 vaccine as required by facility policy. Both residents were admitted to the facility and subsequently sent to the Emergency Department, where they tested positive for COVID-19 before being re-admitted. A review of their medical records revealed that there was no documentation of COVID-19 vaccine consent or refusal prior to their positive diagnoses. During an interview, the Infection Preventionist confirmed that the residents were not offered the vaccine upon admission, which is a standard part of the facility's admission process. The facility's policy states that all residents are to be evaluated for vaccine status and offered recommended vaccines upon admission unless medically contraindicated.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents across all four units, as evidenced by multiple resident interviews, staff interviews, observations, and record reviews. Several residents reported excessive wait times for assistance after activating call lights, with one resident waiting up to an hour and a half and another waiting two hours for help with toileting. These residents had significant medical needs, including hemiplegia, heart failure, muscle weakness, and impaired mobility, and some were unable to perform activities of daily living without staff assistance. Observations also revealed residents left unattended in common areas, including one resident attempting to stand unsafely from a wheelchair and another struggling to move his wheelchair without staff present. Resident Council meeting minutes over several months documented ongoing concerns about delayed call light responses, indicating a persistent issue. A resident representative expressed frustration about unaddressed falls and unanswered call lights, particularly on weekends. Staff interviews consistently described chronic staffing shortages, unpredictable assignments, and difficulty completing tasks, especially during weekends and meal times. Staff members reported frequent call-offs and described staffing as 'hit or miss,' with some stating they had become accustomed to the inadequate staffing levels. The staffing coordinator and DON acknowledged that staffing decisions were primarily based on numbers rather than resident needs, and admitted that required staffing levels were not always met, particularly on weekends and certain shifts. Despite daily reviews of staffing with the NHA and SC, the DON stated being unaware of any staffing concerns. The facility's policy required sufficient staff to meet resident needs according to care plans, but the evidence showed this standard was not consistently met, resulting in unmet resident needs and delayed care.
Failure to Implement Policies to Prevent Abuse and Neglect
Penalty
Summary
The facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. This deficiency was identified in the employee files of six staff members, including LPNs, RNs, and CNAs. The facility's policy titled 'Resident Rights to Freedom from Abuse, Neglect, and Exploitation' lacked procedures for screening employees or verifying prior employment. Interviews with the Nursing Home Administrator (NHA) revealed that this was the only policy in place, indicating a lack of comprehensive measures to prevent such incidents. The review of employee files showed that while Level 2 background screenings were completed prior to employment, the employees were not added to the Background Clearinghouse in a timely manner, which would notify the facility if an employee was charged with a disqualifying offense. Additionally, no reference checks were completed for prior employment history for any of the six employees reviewed. The NHA stated that the expectation was to have background checks completed before employment, employees added to the Clearinghouse within five days of hire, and reference checks completed prior to employment, but these procedures were not followed, leading to the deficiency.
Failure to Honor Resident's Preference for Female Caregivers
Penalty
Summary
The facility failed to honor a resident's preference for female caregivers, compromising the resident's right to a dignified existence and self-determination. Resident #8, who was mentally intact with a BIMS score of 15, had explicitly requested female caregivers for incontinence care, as documented in her care plan. Despite this, the facility's assignment sheets showed that male caregivers, including those the resident specifically did not want, were assigned to her on multiple occasions. Interviews with the Unit Manager and Director of Nursing confirmed these assignments and acknowledged the availability of female caregivers on those days. The Director of Nursing admitted uncertainty about the system in place to ensure resident preferences were honored, despite having provided a list of residents requesting no male caregivers. The Nursing Home Administrator expected that such preferences would be documented in the resident's Kardex and care plan and honored by the unit manager and clinical leadership team. The facility's policy on Resident Rights emphasized treating residents with dignity and respecting their self-determination, which was not upheld in this case.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to adequately address grievances filed by two residents, leading to a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal. Resident #3 reported multiple grievances, including delayed response to call lights, improper meal tray setup, and issues with medication administration. Despite filing grievances, the resident did not receive feedback or resolution from the Social Services Director (SSD), and the grievance forms lacked documentation of investigations or actions taken. Resident #8 and their representative also expressed concerns about the timeliness of assistance and filed grievances regarding call light response. However, there was no record of these grievances in the facility's log, indicating a failure to document and address the resident's concerns. The Nursing Home Administrator (NHA) acknowledged speaking with the resident's representative but could not confirm specific actions taken to resolve the issues. The facility's grievance policy outlines procedures for filing, documenting, and resolving grievances, but these procedures were not followed in the cases of Residents #3 and #8. The SSD and other staff members failed to investigate and resolve the grievances, and there was a lack of communication with the residents about the outcomes. This deficiency highlights a breakdown in the facility's grievance process, resulting in unresolved resident concerns and a failure to uphold residents' rights.
Deficiencies in Resident Care and Protocol Adherence
Penalty
Summary
The facility failed to provide timely repositioning, skin integrity checks, and incontinence care for a resident with multiple comorbidities, including pressure ulcers and paraplegia. The resident expressed concerns about not being repositioned or changed for extended periods, leading to fears of wound reopening. Observations and interviews revealed that the resident was left without care from 10 a.m. to 3 p.m., resulting in skin irritation and emotional distress. The CNA responsible admitted to not checking or changing the resident as required, citing a lack of training at the facility. Additionally, the facility did not adhere to its protocol for lift transfers. A CNA transferred the resident using a full body sling lift without assistance, contrary to the care plan that required two-person assistance. The CNA acknowledged the breach of protocol, attributing it to the inability to find help and a lack of specific training at the facility. The DON confirmed that the transfer should have been conducted with two staff members, as per the resident's care plan. The facility also failed to ensure a call light was within reach for another resident, resulting in the resident being unable to request assistance during breakfast. The CNA responsible did not check on the resident after delivering the meal tray, leaving the call light on the floor. Furthermore, the facility did not administer medications per physician orders for the resident with pressure ulcers. The resident's Zolpidem medication was not reordered in a timely manner, leading to missed doses. The DON confirmed discrepancies in medication administration records and acknowledged the failure to reorder the medication promptly.
Staffing Deficiencies Lead to Resident Neglect
Penalty
Summary
The facility failed to ensure sufficient nursing staff with the appropriate competencies and skill sets to provide necessary care and services to residents, resulting in multiple deficiencies. Observations and interviews revealed that residents were not receiving timely wound care, with bandages remaining unchanged for extended periods, leading to concerns about potential infections. Residents expressed dissatisfaction with the lack of response to call bells, inadequate assistance with activities of daily living (ADLs), and insufficient showering and bathing schedules. The facility's staffing shortages were evident, with reports of call lights going unanswered for extended periods and residents not receiving necessary assistance with meals. The deficiency was further highlighted by the inadequate response to residents' needs during mealtimes, where residents were left unattended and without assistance, leading to some residents being unable to eat. Interviews with staff and residents indicated that the facility was consistently understaffed, with CNAs and nurses unable to meet the demands of the resident population. Staff reported working double shifts and being unable to provide more than basic care due to the high workload and insufficient staffing levels. The facility's management was aware of the staffing issues, with reports of call-offs and no-shows exacerbating the problem. Despite attempts to fill positions with agency staff, the facility struggled to maintain adequate staffing levels, leading to neglect of resident care. The deficiency was severe enough to result in an Immediate Jeopardy determination, indicating a significant risk to resident safety and well-being.
Removal Plan
- Current staffing model reviewed and updated to reflect resident needs and acuity.
- Facility assessment reviewed and updated to reflect current resident population needs.
- Reassessed the acuity level of each unit. Reviewed assistance the level of care needs for ADLs including transfer status, mechanical lift usage, and residents requiring a higher level of care due to comorbidities.
- Education provided to the staffing team to include administration, Director of Nursing, and staffing coordinator regarding staffing standards and staffing for acuity on each unit to ensure quality resident care.
- Initial audit completed to compare the AHCA report to the PPD report and compare with schedules to ensure that PPD was met, and ratios were appropriate for the resident acuity. Administrator, staffing coordinator and payroll coordinator reviewed staffing from the previous day to ensure that hours and ratios were achieved according to the staffing plan based on acuity. Payroll ran the PPD report from the payroll software, after editing missed punches, to compare and enter into the AHCA staffing sheets to encompass hours from the previous day. Staffing coordinator reviewed the schedule for the current day and next day to review attendance and staffing needs to ensure that resident needs are met, and staff are within the ratio of the staffing model. It is the administrator's responsibility to ensure that the staffing model is updated, and the facility assessment is completed to reflect resident acuity needs on each unit.
Facility's Failure to Secure Safe Evacuation Locations During Hurricanes
Penalty
Summary
The administration of the facility failed to update their emergency plan and secure a safe evacuation location, leading to a chaotic and unsafe evacuation during two hurricanes. The facility had an evacuation agreement with a local church, which was terminated due to the facility not following agreed-upon safety and cleanliness procedures. Despite being aware of the termination, the Nursing Home Administrator (NHA) did not secure an alternative location and relied on the local County Emergency Management for assistance, which was not provided. As a result, during the evacuation for the first hurricane, residents were moved to an unsafe location, leading to police and emergency services intervention. During the evacuation for the second hurricane, the facility again failed to secure a safe location, resulting in residents being moved to a church that was deemed unsuitable by local authorities. The conditions at the evacuation site were overcrowded, lacked necessary supplies, and posed significant safety risks, including inadequate space, lack of fire suppression, and insufficient power for medical equipment. The local authorities had to intervene and relocate the residents to a more suitable location, highlighting the facility's failure to ensure the safety and care of its residents during emergencies. Interviews with staff and residents revealed the disorganization and lack of communication during the evacuations. Staff reported confusion, inadequate supplies, and insufficient staffing to care for residents properly. Residents experienced discomfort and distress due to overcrowding and lack of proper facilities. The facility's failure to plan and execute a safe evacuation resulted in immediate jeopardy, with ongoing concerns about the safety and well-being of the residents.
Inadequate Emergency Preparedness Leads to Unsafe Evacuation
Penalty
Summary
The facility failed to maintain an effective governing body that was aware of and updated the facility's emergency plans, leading to a chaotic and unsafe evacuation during Hurricane [NAME]. The governing body was not informed that the facility's evacuation agreement with a local church had been terminated, and no alternative evacuation location was arranged. As a result, when an evacuation was ordered, the facility staff moved 226 residents to an unapproved and unsafe church location. The conditions at this location were deemed unsafe by local authorities, leading to the relocation of residents to a county shelter. During the evacuation, two residents suffered harm due to the lack of supplies and supervision. One resident sustained a fracture after falling, and another resident did not receive necessary wound care treatment. The facility's emergency management plan was outdated and not properly communicated to the governing body, resulting in a lack of preparedness and organization during the evacuation. Staff interviews revealed confusion, inadequate staffing, and insufficient resources to care for the residents during the evacuation. The facility's failure to secure an approved evacuation location and the lack of a comprehensive emergency plan created a situation of immediate jeopardy for the residents. The governing body was not aware of the termination of the evacuation agreement, and the facility did not have a plan in place to ensure the safety and care of its residents during an emergency. This led to a worsened condition for two residents and posed a serious risk to all facility residents.
Neglect and Inadequate Supervision in LTC Facility
Penalty
Summary
The facility failed to protect residents from neglect, resulting in multiple incidents of harm. Resident #3, who required maximum assistance with activities of daily living due to dementia and other health conditions, suffered a hip fracture during a transfer. The investigation into the incident was inadequate, with conflicting accounts from staff and no clear determination of how the injury occurred. The facility did not report the incident as abuse or neglect, and there was a lack of proper documentation and communication with the resident's primary care provider. Resident #8, who was dependent on assistance for all activities of daily living, fell from bed due to improper handling by a CNA. The CNA attempted to clean the resident alone, despite the resident's known behavioral issues and the slippery nature of the air mattress. The facility's care plan did not specify the level of assistance required, leading to confusion among staff. The incident resulted in significant injuries, including a subdural hemorrhage and nasal bone fractures, yet the facility did not conduct a thorough investigation or provide additional training to staff. Resident #12, who had moderate cognitive impairment and was at risk for falls, was found on the floor during an evacuation. The facility did not assign specific responsibilities to staff during the evacuation, leading to inadequate supervision. The resident was sent to the hospital with stable vital signs, but the facility did not conduct a post-storm assessment to evaluate the impact of the evacuation on residents. The lack of organization and communication during the evacuation contributed to the resident's fall and subsequent hospitalization.
Inadequate Supervision and Hazardous Environment Lead to Resident Injuries
Penalty
Summary
The facility failed to provide a hazard-free environment and adequate supervision for three residents, resulting in falls and injuries that required hospital transfers. Resident #3, who had a history of Alzheimer's disease and required maximum assistance with activities of daily living, was found with a hip fracture and a urinary tract infection after being transferred to the hospital. The investigation revealed inconsistencies in staff accounts regarding the cause of the fracture, with some staff suggesting it occurred during a transfer, while others mentioned a possible fall. The facility's management did not conduct thorough interviews or investigations to determine the exact cause of the injury. Resident #8, who was dependent on assistance for all activities of daily living due to a stroke and other comorbidities, fell from his bed and sustained a head injury. The CNA responsible for his care attempted to clean him alone, despite the resident's need for two-person assistance due to his condition. The facility's care plan did not specify the level of assistance required, leading to confusion among staff. The lack of clear directives and training on turning and positioning residents contributed to the incident. Resident #12, who had moderate cognitive impairment and required assistance with activities of daily living, fell during an evacuation to a temporary shelter. The facility did not provide adequate supervision or ensure that necessary assistive devices, such as walkers or wheelchairs, were available during the evacuation. The lack of clear assignments and oversight during the evacuation process resulted in the resident's fall and subsequent hospital transfer.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as observed during a survey conducted over five days. Numerous deficiencies were noted across all four resident units, including locked bathroom doors with padlocks, missing ceiling tiles, and bio-growth on ceilings. In some rooms, the air conditioning vents were dirty, and the paint was bubbling and discolored, indicating possible water leakage. Additionally, some resident rooms had electrical hazards, such as outlets pulling away from the wall, and furniture in disrepair, which prevented proper cleaning. The survey also revealed that some common areas, like the sunroom, had furniture emitting offensive odors, and certain corridors had unlocked electrical boxes, posing safety risks. Maintenance issues were prevalent, with some bathrooms being inaccessible due to storage of facility equipment, and some doors not closing properly. Interviews with staff indicated that some restrooms had been non-functional for months, requiring staff to use buckets of water for resident hygiene. The Director of Maintenance acknowledged the issues, noting that the facility uses an electronic work order system to prioritize and address maintenance problems. However, the system's effectiveness was questioned, as many issues remained unresolved. The facility's policy on creating a homelike environment emphasized maintaining a clean and comfortable atmosphere, but the observed conditions contradicted this policy. The maintenance policy outlined responsibilities for keeping the building in good repair, yet the numerous deficiencies indicated a failure to adhere to these standards.
Failure to Report and Investigate Alleged Abuse or Neglect
Penalty
Summary
The facility failed to report alleged violations involving abuse or neglect immediately, as required by state law, for three residents. For one resident, a fracture occurred during a transfer, but the incident was not reported as abuse or neglect. The resident was found with an abnormal posture and in pain, and was later diagnosed with a hip fracture and UTI at the hospital. The facility's investigation concluded the fracture happened during a transfer, but no report was filed because it was not considered a fall. The management team did not conduct interviews, relying instead on written statements, and did not determine how the transfer was conducted. Another resident experienced a fall resulting in a head injury and laceration. The resident was on an air mattress and slipped off the bed during a turn by a CNA, who was unaware of the required assistance level due to a lack of clear directives. The facility did not conduct an investigation or provide staff training on proper turning and positioning techniques. The resident was admitted to the ICU with a subdural hemorrhage and nasal bone fractures. A third resident fell during an evacuation to a church, resulting in a fracture. The resident was found on the floor without a walker or wheelchair, as these items were not brought during the evacuation. The facility did not compile a post-storm assessment or assign specific responsibilities to staff during the evacuation. The fall was unwitnessed, and the resident was sent to the hospital with a fracture.
Deficiencies in ADL Assistance and Resident Care
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for six residents, leading to deficiencies in care. Resident #16 was observed in bed with food on his face and reported not having received a shower or bed bath for about two weeks, despite his care plan indicating he needed assistance with ADLs. His electronic medical records confirmed the lack of showers or bed baths between 09/30/2024 and 10/21/2024. Similarly, Resident #18 reported delays in receiving daily care and infrequent showers, with records showing only one shower in the last 30 days. Resident #7's family member reported that the facility was often short-staffed, resulting in missed showers for the resident. The resident's records showed only one shower in the last 30 days. Resident #17 also expressed concerns about staffing issues affecting his ability to receive showers on scheduled days, although his records indicated he received showers on four occasions in the last 30 days. Additionally, Resident #24 was observed with her breakfast tray out of reach and no call bell accessible, despite her care plan requiring assistance with meals. During a lunch observation, Resident #25 and other residents were left unattended in the dining room, with Resident #25 calling for assistance and not receiving help until surveyors intervened. The facility's policy on ADLs emphasized the need for appropriate care and services, but the observations and interviews indicated a failure to meet these standards.
Failure to Provide Proper Wound Care for Residents
Penalty
Summary
The facility failed to provide proper wound care for four residents, leading to complications and dissatisfaction among the residents. Resident #19 was observed with a bandage on his right forearm that had not been changed since 10/8/24, despite orders for weekly skin checks. The bandage was not documented in the resident's progress notes, and staff were unaware of its presence until it was pointed out. Upon removal, the wound was found to have sanguineous drainage and surrounding bruising, indicating a lack of proper wound care and monitoring. Resident #21 expressed concern over not having his bandages changed for 10 days since admission, despite having multiple wounds on his legs. The resident's bandages were observed to be loose, undated, and blood-soaked, with exposed wounds. The facility failed to obtain wound care orders upon admission, resulting in a delay of five days before orders were put in place. The resident eventually left the facility against medical advice due to the lack of care. Resident #22 did not receive his wound care treatment on several occasions, including during a hurricane evacuation and after returning to the facility. This led to a deterioration in his condition, resulting in hospitalization for severe sepsis and osteomyelitis. Resident #20 was admitted with a bandage on her right leg that had not been changed since admission, and there were no wound care orders in place. Staff were unaware of the wound until it was pointed out, and the bandage was difficult to remove, causing further damage to the wound. The facility's failure to follow its wound care policy and obtain necessary orders contributed to these deficiencies.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications as per physician orders for three residents, leading to a deficiency in pharmaceutical services. Resident #1, who was admitted with conditions such as benign prostatic hyperplasia and chronic pain syndrome, did not receive Flomax on multiple occasions and missed a dose of Lyrica, with no documentation explaining the omissions. Resident #13, with a complex medical history including Type II Diabetes and atrial fibrillation, missed several doses of medications like Metformin and Amiodarone due to them being on order from the pharmacy, but there was a lack of documentation for some missed doses and no notification to the physician for certain medications. Resident #15, diagnosed with epilepsy and chronic pain, also experienced missed doses of medications such as Keppra and Lyrica, with notes indicating they were on order from the pharmacy. Interviews with staff revealed that medications were ordered electronically, but there were delays in receiving them, and the facility's system integration with the pharmacy was cited as a potential issue. The pharmacy confirmed that prescriptions were requested late due to changes in pain management providers, but they made multiple daily deliveries to the facility. The Director of Nursing (DON) acknowledged the lack of documentation and communication regarding the missed medications and attributed some of the issues to the use of agency nurses who did not inform her of the problems. The facility's policy on medication administration emphasizes timely and documented administration, but the deficiency indicates a failure to adhere to these guidelines, resulting in residents not receiving their prescribed medications as required.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide laboratory services as ordered for three residents, leading to deficiencies in care. Resident #14, who was admitted with multiple diagnoses including acute respiratory failure and chronic kidney disease, had several lab tests ordered on different dates. However, the lab results for the tests ordered on 8/26/24 were not found, despite being signed off as completed. Additionally, the lab order on 9/4/24 was not completed, and the subsequent order on 9/5/24 showed abnormal values, indicating a delay in obtaining necessary lab results. Resident #13, admitted with conditions such as urinary tract infection and acute kidney failure, had multiple orders for urinalysis with culture and sensitivity (UA w/ C&S) due to symptoms suggesting a urinary tract infection. Despite several orders placed in September, there were no lab results found for that month. The resident refused the procedure on some occasions, but there was no documentation for other dates, and the lab results were only obtained on 10/22/24, showing bacteria in the urine. Resident #10, with diagnoses including rhabdomyolysis and acute kidney failure, had orders for UA C&S to rule out a urinary tract infection. The orders were inconsistently signed off, and there were issues with collecting urine samples due to the resident's refusal and physical discomfort. Despite multiple attempts, the lab results were only obtained on 10/1/24, showing an abnormal result with bacteria present. Interviews with staff revealed a lack of awareness of these issues, and the laboratory confirmed that several orders were not received, indicating a breakdown in the process of ordering and obtaining lab tests.
Failure to Notify Critical Ultrasound Results
Penalty
Summary
The facility failed to provide follow-up notification for critical radiology results for a resident who was admitted with diagnoses including anemia, Type 2 Diabetes Mellitus, dementia, and an acquired absence of the left great toe. The resident had an ulcer on her left foot, and a wound care provider ordered a wound culture and arterial and venous doppler ultrasound. The ultrasound results showed critical findings, including occlusion of several arteries in the left foot, but there was no evidence of follow-up related to these critical findings in the resident's medical record. Interviews revealed that the Licensed Practical Nurse (LPN) who documented the ultrasound results did not recall discussing the results with anyone. The resident's Primary Care Physician (PCP) was notified of the results and informed of an upcoming appointment with a vascular specialist, but the wound care provider who ordered the ultrasound was not notified of the critical findings. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the wound care provider was unaware of the results, and the facility's system did not flag the results as critical. The facility's policy on lab and diagnostic test results requires that nurses review test results, identify the urgency of communicating with the attending physician, and ensure follow-up on critical findings. However, in this case, the system failed to alert staff to the critical values, and there was a lack of communication and follow-up with the wound care provider. This oversight resulted in a delay in addressing the resident's condition, as evidenced by a later progress note indicating the resident's left foot was cold and blotchy with no pulse, leading to a hospital assessment.
Inadequate Infection Control Practices in Facility
Penalty
Summary
The facility failed to implement effective infection control practices across three out of four units, compromising the safety and sanitation of the environment for residents. Observations revealed multiple instances of staff neglecting hand hygiene protocols, such as entering and exiting resident rooms without washing hands, and handling equipment and resident care items without proper sanitation. Additionally, used gloves were found discarded on the floor, and personal protective equipment (PPE) carts were improperly used, with non-PPE items placed on them. The facility also demonstrated inadequate management of soiled linens and housekeeping practices. Soiled towels and bath cloths were left in the shower room and on the floor, and bags of soiled linen were improperly stored in resident areas. Housekeeping carts were observed in dining areas during mealtimes, and staff failed to adhere to PPE protocols when handling trash and cleaning in rooms with contact precautions. These actions were contrary to the facility's established policies and procedures for infection prevention and control. Interviews with staff, including registered nurses, licensed practical nurses, and housekeeping aides, revealed a lack of understanding and adherence to contact precautions and enhanced barrier precautions. Staff members were unable to articulate the differences between these precautions and failed to follow proper PPE usage and hand hygiene protocols. The Assistant Director of Nursing/Infection Preventionist acknowledged these deficiencies, confirming that the observed practices did not align with the facility's infection control policies.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to properly store medications on one out of four units and in three out of four medication carts. Observations revealed multiple instances of unsecured medication carts and medications left unattended in resident areas. On several occasions, treatment and medication carts were found unlocked and unattended, with no staff in sight. Medications, including a lidocaine patch, Fluticasone Propionate Nasal Spray, and Nystatin topical powder, were observed on bedside tables and nightstands in resident rooms. Additionally, a medication cup with a pill was left on a bedside table, and an unidentified medication was found on the floor in the A-wing hall. Interviews with staff members, including RNs and LPNs, revealed that personal items such as hearing aids, batteries, and water bottles were stored in medication drawers, including those designated for controlled substances. Staff admitted to these practices, acknowledging that medications should not be left at the bedside and that medication carts should be locked when not attended. The facility's policy on medication storage mandates that medications and biologicals be stored securely and only accessible to authorized personnel, which was not adhered to in these instances.
Insufficient Nursing Staff Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to have sufficient nursing staff to provide timely nursing and related services, particularly in relation to answering call lights. Multiple grievances were filed by residents and their families, indicating that call lights were not being answered promptly. Despite staff education and audits, complaints persisted, with residents reporting wait times of 30-45 minutes for assistance. Observations confirmed that call lights were often ignored by staff, even when residents were in urgent need of help, such as needing to use the restroom or requiring pain medication. Resident #173, the Resident Council President, reported ongoing complaints about delayed call light responses during council meetings. Resident #57, who needed frequent restroom assistance due to a medical condition, stated she often waited at least 40 minutes for help. Resident #117, who suffered from a stage 4 pressure ulcer, reported delays in receiving pain medication, with call light response times of at least 30 minutes. These delays were corroborated by direct observations of call lights being ignored by staff members. Interviews with staff members revealed that they were often overwhelmed with the number of residents they had to care for, making it difficult to respond to call lights promptly. CNAs reported having to manage 14-18 residents each, leading to significant delays in providing care. The Staffing Coordinator acknowledged the staffing challenges and confirmed that call lights were sometimes left unanswered when the assigned aide was on break. The facility's policy stated the intent to ensure sufficient nursing staff, but the observed practices and staff testimonies indicated a failure to meet this standard.
Environmental Deficiencies in Resident Living Areas
Penalty
Summary
The facility failed to maintain a clean and comfortable environment in two hallways, specifically the 100 and 200 halls. Observations during the initial tour revealed multiple deficiencies, including soiled toilets, dirty floors, missing tiles, peeling paint, and black/brown bio-growth in various rooms. Additionally, the 200 hall lounge area had missing tiles. The Maintenance Director was unaware of these issues and confirmed there was no policy in place to address the environment. Further observations on subsequent days revealed additional environmental concerns, such as missing paint, rusted light fixtures, and cracked walls in several rooms. Shared shower areas were found to have rust-colored substances, peeling paint, and chipped tiles. The Maintenance Director reviewed photographic evidence of these conditions and admitted to being unaware of the environmental issues. The facility's Physical Environment policy, effective January 1, 2020, mandates a safe, clean, comfortable, and homelike environment for each resident, which was not upheld in this case.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program for two out of four units. Observations on multiple dates revealed the presence of live spiders and roaches in shared shower rooms. Specifically, a spider web with a live spider was found in one shower, and five small live roaches were observed crawling on the shower floor in another room. Staff interviews confirmed the presence of pests and indicated that pest control measures, such as spraying, were not effectively addressing the issue. Housekeeping staff reported finding roach droppings and dirt daily, suggesting an ongoing infestation problem. Despite regular pest control visits, the problem persisted, and maintenance staff were unaware of the severity of the issue in specific rooms. The facility's pest control policy requires staff to report pest sightings to maintenance, who then log the issues for the pest control company to address. However, the review of pest control work orders for the past three months showed a significant number of roach sightings, indicating that the pest control measures were insufficient. The Maintenance Director was unaware of the environmental conditions in the affected rooms, highlighting a communication gap and a failure to effectively manage the pest control program.
Failure to Revise Care Plan for Resident
Penalty
Summary
The facility failed to review and revise a care plan to reflect the nonuse of a secure door safety banner stop sign for a resident. Observations made on multiple occasions showed that the resident was sitting on the side of her bed with her call light within reach, but no stop sign was present across her room door. The resident was admitted with diagnoses including Chronic Kidney Disease, need for assistance with personal care, unspecified dementia with psychotic disturbance, and unspecified mood affective disorder. A Minimum Data Set (MDS) indicated that the resident was severely cognitively impaired. The resident's care plan, dated 3/27/2024, included an intervention for a stop sign across her door due to her risk for abuse and neglect. However, interviews with staff revealed that the resident had never had a stop sign across her door. The RN/Director of MDS stated she did not know why the care plan included this intervention and found no assessments justifying its necessity. The facility's policy requires that care plans be revised as information about residents changes, but this was not done in this case.
Failure to Provide Adequate Personal Grooming for Dependent Residents
Penalty
Summary
The facility failed to provide adequate personal grooming for two residents who were dependent on staff for Activities of Daily Living (ADLs). Resident #3, who was totally dependent for personal hygiene due to functional quadriplegia and other severe conditions, was observed on multiple occasions with facial hair above her lip. Despite the facility's policy on facial hair removal, there was no documentation indicating that shaving was offered or refused for Resident #3. Staff confirmed that shaving should be done on shower days, but it was evident that this was not consistently followed for Resident #3. Resident #9, who had severe cognitive impairment and required substantial assistance with personal hygiene, was observed with dark brown material underneath her nails on multiple occasions. The resident's care plan did not include specific interventions for nail care, and there was no documentation of nail care activities in the resident's progress notes. Staff interviews revealed that nail care was expected to be done on shower days, but there was no evidence that this was consistently performed for Resident #9. The Director of Nursing confirmed that the resident's nails should not have been in such a condition for multiple days. The facility's policies on facial hair removal and nail grooming were not adequately followed, leading to deficiencies in the personal grooming of Residents #3 and #9. The lack of documentation and inconsistent adherence to grooming schedules contributed to the observed deficiencies. Staff interviews corroborated the observations, indicating a failure to meet the daily grooming needs of these residents as required by their care plans and facility policies.
Failure to Label Dressings According to Professional Standards
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, specifically related to the labeling of dressings for a resident with a skin condition. Observations on two separate occasions revealed that the resident had a large white dressing on his left calf that was not labeled with staff initials or a date, contrary to the physician's orders. The orders specified that the dressing should be changed daily and as needed, and should be labeled accordingly. However, the dressings observed on the resident did not meet these requirements. Interviews with staff, including a CNA and the Director of Nursing (DON), confirmed that wound care is typically performed by nurses or a wound care nurse, and that dressings should be dated and initialed following physician orders. The DON stated that the wound care nurse conducts rounds on specific days, while floor nurses are responsible for other wound care. Despite these protocols, the facility did not provide a policy related to the standards of practice for labeling wounds when requested, indicating a lapse in adherence to professional standards of practice for wound care management.
Failure to Ensure Competent Care and Necessary Supplies for Laryngectomy Tube
Penalty
Summary
The facility failed to ensure a resident who cares for his laryngectomy tube was assessed and deemed competent, failed to ensure necessary supplies were available, and failed to ensure follow-up with a specialty physician related to his laryngectomy tube. The resident, who was admitted with multiple respiratory conditions, including a laryngectomy tube, reported that his tube was not long enough, making it harder for him to breathe. Despite having an appointment with an ENT specialist, the resident faced transportation and insurance issues, resulting in the appointment being canceled twice. The resident was observed using normal saline and rolled-up paper towels to clean his laryngectomy tube, which was torn and needed replacement. However, the facility did not provide extra laryngectomy tubes, and the resident was told that new tubes could not be ordered until he saw the ENT doctor. The resident's medical records revealed multiple physician orders related to his laryngectomy care, including the need for an ENT appointment and instructions for trach care. However, there was no documentation indicating that the resident was assessed for his competency in caring for his laryngectomy tube. Interviews with staff members, including the Unit Manager, Nursing Home Administrator, and Director of Nursing, confirmed that the resident did not have the necessary supplies at his bedside, such as an ambu bag, trach ties, suction kit, and an extra laryngectomy tube. The staff also acknowledged that the resident was using inappropriate materials, such as paper towels, to clean his tube. The facility's policy on laryngectomy care and suctioning outlined the proper procedure for cleaning and maintaining a laryngectomy tube, which included using a nylon brush and normal saline. However, the resident was not provided with the appropriate supplies and was not assessed for his competency in performing self-care. The facility's failure to ensure the resident had the necessary supplies and follow-up care with a specialty physician resulted in the resident using improper materials to clean his laryngectomy tube and experiencing difficulty breathing due to the tube's inadequate length.
Failure to Complete Monthly Drug Regimen Review
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review for Resident #135, as required by regulations. The resident had multiple diagnoses, including unspecified dementia with behavioral disturbances, psychotic disorder with hallucinations, and anxiety disorder. Despite these conditions and the complexity of the resident's medication regimen, the drug regimen review for February 2024 was not completed, and there was no documentation of the pharmacist's recommendations in the medical record for that month. The Nursing Home Administrator (NHA) confirmed that Resident #135 was not reviewed by the Pharmacy Consultant in February 2024 due to a glitch in the vendor's system, which was later fixed. However, the lack of review and documentation persisted, as evidenced by the absence of pharmacy recommendations in the resident's progress notes and other medical records from February 2024. The Pharmacy Consultant admitted to the glitch and provided a screenshot of his recommendations, but these were not acted upon by the attending physician or the Director of Nursing (DON). The facility's failure to ensure a consistent and documented drug regimen review for Resident #135 led to the deficiency noted in the report.
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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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