Aviata At Arbor Springs
Inspection history, citations, penalties and survey trends for this long-term care facility in Ocala, Florida.
- Location
- 1501 Se 24th Rd, Ocala, Florida 34471
- CMS Provider Number
- 105465
- Inspections on file
- 36
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Aviata At Arbor Springs during CMS and state inspections, most recent first.
Surveyors found multiple instances of improper labeling and storage of medications on several medication carts, including unlabeled medication cups with tablets, opened insulin vials without open or expiration dates, expired insulin, and ophthalmic solutions lacking required dating. Several unopened insulin vials and other medications labeled by the pharmacy to be refrigerated until opened were instead stored on medication carts. Multiple RNs and LPNs acknowledged during interviews that medications should be labeled with open or expiration dates, expired medications should not remain on carts, and products requiring refrigeration should be kept in a refrigerator, contrary to what was observed. Facility policies require medications to be stored in original labeled containers, under proper conditions per manufacturer instructions, with expired or discontinued medications removed and refrigerated medications maintained at appropriate temperatures.
The facility did not ensure a safe and homelike environment when it failed to repair broken wall tiles in a shower room. A resident reported catching a toe on a missing tile, and surveyors later observed seven broken tiles on a shower room wall, including chipped tiles with sharp edges and deteriorating grout. The Maintenance Assistant acknowledged the tiles were in disrepair and stated that daily shower room tours had not yet included this room that day, despite a facility policy requiring daily rounds to identify and address physical plant hazards.
Nursing staff failed to follow the facility’s hand hygiene policy during multiple medication passes. An RN and an LPN repeatedly prepared medications at the cart, popped pills from blister packs into their bare hands, and entered resident rooms without performing hand hygiene. They touched overbed tables, bed controls, and residents, donned gloves without prior hand hygiene, obtained BPs, and administered medications, sometimes moving directly from one resident to another without cleaning their hands, despite a policy requiring hand hygiene before and after patient care and after contact with inanimate objects in the patient vicinity.
The facility did not provide written notification to residents and their representatives regarding transfers to the hospital, instead giving all transfer documents to EMS and only verbally informing residents of the reason and destination. Multiple LPNs and the DON confirmed this practice, and clinical records lacked documentation of written notification.
A resident with a multi-drug-resistant organism (MDRO) urinary tract infection was placed on contact isolation, requiring staff to use PPE when entering the room. Observation showed a CNA entered the room and handled personal items without donning gown or gloves, despite clear signage and available PPE. Interviews revealed staff misunderstanding of contact precaution requirements, contrary to facility policy and physician orders.
A resident's MDS assessment did not accurately reflect their prescribed controlled carbohydrate, no added salt diet, as indicated by a physician's order. Staff interviews confirmed the discrepancy and the need for the MDS to be updated to match the resident's actual nutritional status.
Two residents did not receive IV therapy care according to professional standards and facility policy. One resident's midline catheter dressing was not changed as required, with dried blood and a compromised dressing observed days after insertion. Another resident had a midline catheter inserted in error due to a misunderstanding of medication orders, resulting in an unnecessary invasive procedure. Staff interviews and documentation confirmed lapses in following orders and established protocols.
A resident with a history of UTIs and a suprapubic catheter was started on Ertapenem for a suspected UTI without clinical or laboratory evidence to support the diagnosis. Despite the absence of fever and normal lab values, the antibiotic was continued after a urine sample was not collected, and no urinalysis or culture was performed. Facility staff acknowledged the failure to obtain the necessary labs and to discontinue the antibiotic in the absence of infection.
A resident with complex medical needs was started on Ertapenem for a suspected UTI without supporting clinical evidence or laboratory confirmation. Despite orders for urinalysis and urine culture, no samples were collected, and the antibiotic was continued without follow-up or discontinuation. Staff interviews confirmed that the facility's antibiotic stewardship policy was not followed, resulting in unmonitored antibiotic use.
A resident with chronic respiratory conditions was observed receiving oxygen at 2 liters per minute, contrary to the physician's order of 5 liters per minute with humidification. The DON confirmed the discrepancy, highlighting the need for staff to verify and follow physician orders.
The facility did not post daily nurse staffing information as required. On observation, the staffing information in the lobby was outdated by three days. The Administrator confirmed the expectation for daily updates but admitted there was no policy for posting this information.
A resident with multiple health conditions was unable to be transferred out of bed for three days due to dead batteries in the mechanical lift. Staff reported issues with battery charging and were unable to find charged batteries in other units. The DON was unaware of the problem, and the resident remained in bed due to the equipment malfunction.
The facility failed to maintain a clean environment, with multiple observations of dead pests and cobwebs in residents' rooms. Residents expressed dissatisfaction with the presence of bugs, and the housekeeping staff acknowledged the issue. The Housekeeping Supervisor noted that rooms should be cleaned daily, but the facility's approach to pest control may have contributed to the problem.
A resident with pressure ulcers did not receive the ordered dietary supplement, Juven, on multiple occasions. The LPN and dietician were unaware of its unavailability and did not inform the physician. The DON emphasized the importance of following physician orders and notifying them if orders cannot be fulfilled.
A resident fell while transferring from a wheelchair to a bed due to malfunctioning bed locks. Despite previous reports of bed issues, the facility lacked a routine maintenance schedule and staff awareness regarding bed safety checks. The Director of Nursing confirmed no corrective actions or staff education were initiated following the incident.
The facility failed to ensure proper hand hygiene and infection control practices during medication administration, wound care, and other resident care activities. Staff did not follow enhanced barrier precautions for residents with indwelling medical devices and wounds, and there was a lack of signage and PPE availability. These deficiencies were observed across multiple staff members and residents, leading to potential risks of infection.
The facility failed to ensure proper medication administration for residents with enteral tubes and central catheters. Nurses did not verify tube or catheter placement, flush between medications, or follow proper procedures for crushing and administering medications. Additionally, a resident was observed self-administering medication left at their bedside.
The facility failed to provide appropriate wound care for multiple residents, including not changing dressings daily as ordered and not following proper infection control procedures. Residents reported and observations confirmed that wound care was often neglected, leading to improper wound management.
The facility failed to provide appropriate enteral nutrition care for two residents. One resident received incorrect feeding and flush rates, while another had outdated gastric tube dressings and was not evaluated for the necessity of the feeding tube despite consuming food and medication orally.
The facility failed to ensure accurate medical records for several residents, leading to deficiencies in wound care, central catheter care, and feeding tube care. Multiple instances of missing documentation were observed, and staff interviews confirmed that care was not documented as required.
The facility failed to develop a comprehensive care plan for a resident who only speaks Spanish, resulting in communication difficulties. The resident's primary language was noted in the MDS, but this information was not included in the care plan, contrary to the facility's policy and procedures.
The facility failed to provide appropriate respiratory care for two residents. One resident received incorrect oxygen levels, and an LPN did not follow sterile technique during a tracheal suctioning procedure. Another resident received oxygen via nasal cannula instead of the prescribed tracheostomy collar.
Improper Labeling and Storage of Insulin and Other Medications on Multiple Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals, particularly insulin and ophthalmic solutions, were properly labeled, stored, and maintained in accordance with professional standards and facility policy. During observation of medication cart #1 with an RN, surveyors found two unlabeled medication cups containing multiple tablets, as well as several insulin vials that were either opened without a date or expired, and multiple unopened insulin vials labeled by the pharmacy to be refrigerated until opened but stored on the cart instead. The RN acknowledged that medications should not be unlabeled, should not be pre-poured and left on the cart, and that insulin requiring refrigeration should not be kept on the cart and that expired insulin should not be present. On medication cart #2, observed with an LPN, surveyors identified an unopened Lispro insulin that should have been refrigerated until opened and multiple Latanoprost and Timolol ophthalmic solutions that were either missing open dates or expiration dates, with the LPN stating that all medicines should be in the refrigerator if required, labeled with open dates, and removed if expired, and acknowledging that the eye drops were expired. On medication cart #4, another LPN was observed with Lantus and Novolin insulin vials that lacked open dates or expiration dates, along with an unopened Lantus insulin that should have been refrigerated until opened; the LPN stated that all medications should have open or expiration dates and remain refrigerated until needed. On medication cart #5, surveyors found multiple unopened insulin vials labeled to be refrigerated until opened stored on the cart, an opened Lantus insulin without pharmacy packaging or resident identification and without open or expiration dates, an opened Aspart insulin without dates, and two expired insulin vials with documented open dates; the LPN confirmed there should not be expired medicines on the cart and that insulins should be labeled and refrigerated when not in use. Further observations on medication carts #6 and #7 revealed additional issues with insulin storage and labeling. On cart #6, there were unopened Aspart and Lantus insulin vials labeled to be refrigerated until opened and an opened Lispro insulin without an open date or expiration date; the LPN stated that every insulin should have an open or expiration date and that unused insulin should remain in the refrigerator. On cart #7, surveyors found an expired Lispro insulin with an open date, unopened Glargine and Humulin insulins that were labeled to be refrigerated until opened but stored on the cart, and an opened Novolin insulin without an open date or expiration date; the LPN stated that every insulin needs expiration dates and unopened insulins should stay in the refrigerator. Review of facility policies confirmed that medications are required to be stored in original labeled containers, under proper conditions per manufacturer instructions, with expired or discontinued medications removed, and that medications requiring refrigeration must be stored at 2–8°C (36–46°F).
Failure to Maintain Safe and Intact Shower Room Surfaces
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment when it did not repair broken and damaged wall tiles in a resident shower room. A resident reported that there was a missing shower tile in the shower room and that she caught her toe on it in January. On observation of the 400's hall shower room, surveyors noted seven broken wall tiles on the wall adjacent to the door, including two tiles that were chipped with sharp edges exposed and an uneven surface with deteriorating grout. During interview, the Maintenance Assistant acknowledged that the tiles were in disrepair and stated that he tours the shower rooms daily but had not yet toured this particular shower room that day. Review of the facility’s Maintenance policy, last approved on 01/15/2026, showed that the Director of Environmental Services is responsible for daily rounds of the building to ensure the physical plant is free of hazards and in proper condition, indicating that the damaged tiles were not identified and corrected as required by the facility’s preventive maintenance procedures.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not ensuring staff performed required hand hygiene during medication administration. During multiple observations of medication passes, a Registered Nurse (Staff A) and a Licensed Practical Nurse (Staff C) repeatedly approached and used the medication cart, unlocked it, activated and typed on the computer, and prepared medications without performing hand hygiene. Staff A was observed popping multiple medications from blister packs directly into their bare hand before placing them into medication cups for several residents, and then entering resident rooms without hand hygiene, touching overbed tables, bed controls, and residents, and donning gloves without prior hand hygiene before taking blood pressures and administering medications. Staff A acknowledged during interview that they should not have touched the medications with their hands and should have used hand sanitizer more frequently. Similarly, Staff C was observed returning to the medication cart multiple times, unlocking it, activating and typing on the computer, and preparing medications for several residents without performing hand hygiene. Staff C then entered resident rooms without hand hygiene, touched overbed tables, bed controls, and residents, obtained blood pressures, and administered medications, and in some instances exited rooms and immediately began preparing medications for other residents without performing hand hygiene. During interview, Staff C stated they should have used the hand sanitizer available on the cart. Review of the facility’s “Hand Hygiene” policy, last approved on 1/15/2026, showed that hand hygiene is required before and after patient care and after contact with inanimate objects in the immediate patient vicinity, which was not followed in these observed instances.
Failure to Provide Written Transfer Notification to Residents and Representatives
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding transfers to the hospital, including the reasons for the transfers, for three residents reviewed for discharge or transfer. Clinical records for each resident contained transfer forms and discharge notices indicating the date and destination of the transfer, but there was no documentation that written notification was given to the residents or their representatives. Instead, staff reported that all transfer documents were provided to EMS, and only verbal explanations were given to the residents about the reason for transfer and the destination. Interviews with multiple LPNs and the Director of Nursing confirmed that the practice was to verbally inform residents of the transfer and provide all paperwork to EMS, rather than directly to the residents or their representatives. Staff also indicated that they did not provide written documentation to residents at the time of transfer, citing concerns that the paperwork might get lost. The facility's policy stated that transfers or discharges should be safe, orderly, and appropriate to meet the needs of the resident, but did not specify the process for written notification to residents or their representatives.
Failure to Follow Contact Precaution Protocols for Resident with MDRO UTI
Penalty
Summary
Staff failed to follow established infection control standards for transmission-based precautions for a resident admitted with a diagnosis of pseudomonas aeruginosa urinary tract infection, a multi-drug-resistant organism. Physician orders and facility policy required contact isolation, including the use of personal protective equipment (PPE) such as gowns and gloves upon entering the resident's room. Observation revealed that a CNA entered the resident's room without donning any PPE, despite clear signage and readily available PPE at the door. The CNA handled the resident's personal belongings on the bedside table and then exited the room without wearing gloves or a gown. Interviews with the CNA, LPN supervisor, and Director of Nursing confirmed that staff were expected to wear appropriate PPE when entering rooms under contact precautions. The CNA stated a misunderstanding of the requirements, believing PPE was only necessary when directly caring for the resident, not when entering the room or handling items. Facility policy and posted signage both specified that gloves and gowns must be worn upon entry to the room, regardless of the nature of the visit, to prevent the spread of infection.
Inaccurate MDS Assessment of Resident's Therapeutic Diet
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the nutritional status of a resident. Specifically, the annual Minimum Data Set (MDS) for one resident indicated that the resident was not on a therapeutic diet, as documented under Section K - Swallowing/Nutritional Status. However, a physician's order dated several months prior specified that the resident was to receive a controlled carbohydrate diet with no added salt. During interviews, the MDS Coordinator acknowledged that the MDS would need to be modified to reflect the resident's actual diet, and the Director of Nursing confirmed that the MDS should accurately represent the resident's information.
Failure to Follow IV Therapy Standards and Orders for Two Residents
Penalty
Summary
The facility failed to provide care and services according to professional standards of practice for two residents receiving IV therapy. For one resident, a midline catheter was inserted in the left upper arm for IV fluids, but the transparent dressing over the insertion site was observed to be lifting at the edges, with dried blood visible on gauze beneath the dressing. The dressing was dated nine days prior and had not been changed as required by both physician orders and facility policy, which specify dressing changes every 5-7 days or sooner if compromised, and every 48 hours if gauze is present. Staff interviews confirmed the dressing should have been changed, and the resident reported it had not been changed since insertion. Another resident had a midline catheter inserted in error after staff misinterpreted medication orders, believing IV access was needed for antibiotic administration. The resident received all doses of the prescribed medication intramuscularly, as originally intended, and the midline was removed the following day after the mistake was identified. Documentation and staff interviews revealed that the midline was not used for medication administration, and the error was due to a misunderstanding of the medication route. The advanced practice provider confirmed that no order was given for IV administration or midline insertion. Facility policy requires a provider order and written consent for midline or PICC insertion, and specifies dressing change intervals to prevent infection. In both cases, the facility did not follow its own policies or professional standards, resulting in improper catheter care and an unnecessary invasive procedure.
Unnecessary Antibiotic Use Without Laboratory Confirmation
Penalty
Summary
A deficiency occurred when a resident with a history of urinary tract infections (UTIs) and a suprapubic catheter was started on Ertapenem, a broad-spectrum antibiotic, for a suspected UTI without adequate clinical indications or supporting laboratory evidence. The physician ordered a urinalysis with reflex culture, but the urine sample was not collected, and no urinalysis or urine culture results were documented. Despite the absence of fever, normal white blood cell count, and lack of other clinical signs of infection, the antibiotic regimen was continued. Interviews with facility staff, including the Infection Preventionist, LPN, DON, and Advanced Practice Registered Nurse, confirmed that the antibiotic should not have been continued without laboratory confirmation of infection. Staff acknowledged that there was a failure to follow up on obtaining the necessary urine sample and to discontinue the antibiotic in the absence of supporting evidence. This resulted in the resident receiving unnecessary antibiotics, contrary to facility policy and best practices for antimicrobial stewardship.
Failure to Monitor and Manage Antibiotic Use per Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program by not adequately monitoring and managing the use of antibiotics for a resident with multiple complex medical conditions, including quadriplegia, tracheostomy, and a history of urinary tract infections (UTIs). The resident was started on Ertapenem for a suspected UTI based on a physician's order, despite the absence of clinical signs such as fever or elevated white blood cell count. Although a urinalysis and urine culture were ordered, no samples were successfully collected, and there were no laboratory reports or follow-up orders for these tests during the relevant period. Staff interviews revealed that the antibiotic was continued without confirmation of infection, and there was a lack of follow-up to obtain the necessary urine sample or to discontinue the antibiotic in the absence of supporting evidence. The Infection Preventionist, LPN, DON, and Advanced Practice Registered Nurse all acknowledged that the facility's antibiotic stewardship policy was not followed, as antibiotics were administered empirically without culture results or clear clinical indications, and appropriate communication and documentation were lacking.
Failure to Administer Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure that a resident received the correct oxygen flow rate as prescribed by their physician. During observations, it was noted that the resident was receiving oxygen at a flow rate of 2 liters per minute via a tracheostomy mask, despite the physician's order specifying a flow rate of 5 liters per minute with humidification. The resident, who was admitted with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and sleep apnea, was not receiving the prescribed level of oxygen. The Director of Nursing confirmed that the resident's oxygen flow rate was incorrect and emphasized that staff should review and verify physician orders to ensure compliance with prescribed treatments.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted on a daily basis. During an observation on February 6, 2025, at 8:45 AM, it was noted that the nurse staffing information displayed in the front lobby was outdated, showing the date of February 3, 2025. In an interview conducted on the same day at approximately 9:00 AM, the Administrator acknowledged that the expectation was to have the staffing information posted and readily available with the correct information at the beginning of each shift. However, it was revealed that the facility did not have a policy in place for posting the nurse staffing information.
Failure to Transfer Resident Due to Equipment Malfunction
Penalty
Summary
The facility failed to ensure that a resident was transferred out of bed using a mechanical lift, as required by their care plan. The resident, who had multiple diagnoses including type 2 diabetes mellitus, hypertension, obesity, and a history of cerebrovascular accident, was unable to be transferred out of bed for three consecutive days due to dead batteries in the Hoyer lift. The resident expressed that the lift had dead batteries from Friday to Sunday, preventing them from getting out of bed. Interviews with staff members revealed that there was an ongoing issue with the batteries not charging properly. Staff members attempted to find charged batteries by checking other units but were unsuccessful. The Director of Nursing was unaware of the battery issue and stated that staff were expected to obtain batteries from other areas if needed. Despite these expectations, the resident remained in bed due to the lack of functioning equipment.
Facility Fails to Maintain Clean Environment Due to Pest Presence
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by multiple observations of dead pests and cobwebs in several residents' rooms. During an observation, a dead brown small pest was found in a cobweb high on the wall in a resident's room. The resident expressed dissatisfaction with the presence of bugs in their room. Another resident's room had peeling baseboards with multiple dead pests inside, as well as cobwebs containing dead pests on the walls and above the windows. This resident reported seeing live bugs, particularly in the bathroom, and expressed uncertainty about whether the facility had conducted pest control measures. The housekeeping staff, including a housekeeper and the Housekeeping Supervisor, acknowledged the presence of dead pests in cobwebs during their observations. The Housekeeping Supervisor confirmed that the rooms should be cleaned and dusted daily, with cobwebs and bugs removed regularly. He noted that the facility was treating one hall at a time, which might have contributed to the issue of bugs in some rooms. The observations and interviews indicate a failure to provide a clean and safe environment for the residents, as required by regulations.
Failure to Administer Dietary Supplement as Ordered
Penalty
Summary
The facility failed to provide a dietary supplement, Juven, as ordered for a resident with pressure ulcers, paraplegia, muscle wasting, and atrophy. The physician's orders specified that Juven should be administered twice daily, but the Medication Administration Record showed that it was not given on several occasions. There was no documentation indicating that the physician or nutritionist was informed about the unavailability of the supplement. Interviews revealed that the resident expressed concern about not receiving the supplement, which was intended to aid in wound healing. Staff members, including an LPN and the dietician, confirmed that they were unaware of the supplement's unavailability and did not notify the physician. The Director of Nursing stated that physician orders should be followed, and any inability to do so should be communicated to the physician.
Failure to Maintain Bed Safety Leads to Resident Fall
Penalty
Summary
The facility failed to ensure a safe environment for a resident by not maintaining the functionality of the bed locks, which led to an accident. A resident, who had a history of independently transferring from a wheelchair to a bed, reported that the bed was not locked, causing it to move and resulting in a fall. The resident had previously reported issues with the bed, including a malfunctioning lock and problems with the bed not lowering, which were documented in work orders. Despite these reports, there was no evidence of a routine maintenance schedule to check the beds for safety, and the maintenance director confirmed that checks were only performed when issues were reported by residents or staff. Interviews with staff, including the Director of Nursing and a Registered Nurse, revealed a lack of awareness and responsibility for checking bed functionality. The Director of Nursing acknowledged that no corrective plan was initiated after the bed malfunction was identified, and no routine checks or staff education on bed safety were implemented. This lack of proactive measures and communication contributed to the unsafe environment that led to the resident's fall.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure staff performed proper hand hygiene during medication administration, wound care, and other resident care activities. Multiple observations revealed that staff members, including RNs and LPNs, did not wash their hands or use hand sanitizer before and after administering medications, handling medical equipment, or performing wound care. This was observed across several residents, including those with complex medical needs such as gastrostomy tubes, tracheostomies, and stage 4 pressure ulcers. Staff members admitted to not following hand hygiene protocols during interviews, and the facility's policies clearly outlined the necessity of hand hygiene to prevent the spread of infection. The facility also failed to implement enhanced barrier precautions for residents with indwelling medical devices and wounds. Observations showed that there was no signage indicating enhanced barrier precautions, and PPE supplies were not available in or near the rooms of affected residents. Staff members did not don gowns when providing high-contact care activities, such as wound care, tracheostomy care, and medication administration via gastrostomy tubes. Interviews with staff revealed a lack of awareness and adherence to the enhanced barrier precautions, despite physician orders and care plans indicating the need for such measures. Additionally, the facility did not follow proper infection control standards during wound care procedures. Staff members were observed not cleaning overbed tables before placing wound care supplies, not performing hand hygiene between glove changes, and contaminating sterile supplies by touching non-sterile surfaces. These actions were contrary to the facility's policies on dressing changes and wound care, which emphasized the importance of maintaining a sterile environment to promote healing and prevent infections. The Director of Nursing acknowledged the deficiencies and stated that staff should follow the established policies and procedures for infection control.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper medication administration for residents with enteral tubes and central catheters. During an observation, a registered nurse administered medications to a resident with an enteral tube without verifying tube placement, flushing between medications, or using gravity flow. The nurse admitted to not following the facility's policy, which requires checking for gastric residual volume and flushing the tube with water between each medication. Another incident involved a resident with a midline catheter where the nurse did not properly clean the needleless connector, verify catheter placement, or assess the insertion site before administering IV medication. The Director of Nursing confirmed the lack of a specific central line flush policy and expected procedures were not followed. Additionally, a resident was observed self-administering medication left at their bedside, which is against facility policy. Another nurse was seen crushing and administering multiple medications together via a gastric tube, contrary to the policy that requires each medication to be crushed and administered separately. The Director of Nursing acknowledged that the staff did not adhere to the proper procedures for medication administration via enteral tubes and that medications should not be left at the bedside for residents who are not capable of self-administration.
Failure to Provide Appropriate Wound Care
Penalty
Summary
The facility failed to ensure that residents received wound care treatment in accordance with professional standards of practice. Resident #91, who had a stage 4 pressure ulcer, did not receive daily wound care as ordered by the physician. The dressing was observed to be dated incorrectly, and there were multiple days where no entries were documented in the Treatment Administration Record. Additionally, a family member had to perform wound care due to the facility's inaction, and staff failed to follow proper infection control procedures during care observations. Resident #73 had a left heel dressing that was not changed daily as required. The resident reported that staff often forgot to change the dressing, and observations confirmed that the dressing was not changed for several days. Staff interviews corroborated that the dressing should have been changed daily but was not. Resident #133 and Resident #155 also did not receive appropriate wound care. Resident #133's right thigh dressing was not changed daily as ordered, and the resident reported that staff had not attended to the wound care as required. Resident #155 had a surgical wound with a dressing that was not changed according to the physician's orders, and the wound vac was not applied due to a lack of supplies. The facility's documentation and staff interviews confirmed these deficiencies in wound care treatment.
Failure to Ensure Appropriate Enteral Nutrition Care
Penalty
Summary
The facility failed to ensure appropriate care and services for enteral nutrition for two residents. For Resident #96, observations revealed discrepancies between the physician's orders and the actual administration of the feeding and flush rates. The resident's feeding machine was found beeping with empty formula and water bags, and the feeding rate was consistently observed at 50 ml/hr, contrary to the physician's order of 55 ml/hr. Additionally, the autoflush rate was running at 60 ml/hr instead of the ordered 40 ml/hr. The resident experienced a slight weight loss, which the Registered Dietician noted could be affected by the incorrect feeding rate. The Director of Nursing confirmed that nurses should verify the orders and the milliliters that a feeding and flush should be running. For Resident #151, the facility failed to change the gastric tube dressing as per the physician's orders. The resident's tube feeding dressing was observed to be dated several days prior, and the resident reported that the dressing had not been changed for days. The resident also mentioned that they no longer needed the feeding tube as they were consuming food and medication orally. Physician orders indicated a regular diet and daily dressing changes, which were not followed. The Director of Nursing acknowledged that the resident should have been evaluated earlier and that the dressing should be changed daily according to physician orders.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to ensure accurate medical records for several residents, leading to deficiencies in wound care, central catheter care, and feeding tube care. For Resident #91, there were multiple instances where wound care and tracheostomy care were not documented in the Treatment Administration Record (TAR) for May 2024. This included missing entries for cleansing and dressing the coccyx and tracheostomy site, as well as suctioning the tracheostomy tube. Similarly, Resident #260's TAR showed missing documentation for wound care and enteral tube care on several dates in May 2024. Resident #73's TAR also lacked documentation for wound care on specific dates in May 2024. During an interview, a Licensed Practical Nurse (LPN) confirmed that all wound care should be documented, and the Director of Nursing (DON) stated that nurses should follow accepted standards for documentation. Resident #133's right thigh dressing was observed to be dated incorrectly, and the TAR showed discrepancies in the administration of care. The DON confirmed that staff should follow physician orders for treatment. Resident #151's tube feeding dressing was observed to be outdated, and the resident reported that the dressing had not been changed for days. The TAR showed staff initials for care that was not provided. Resident #155 had a visibly soiled abdominal wound dressing, and the TAR showed missing entries for wound care. The DON stated that nursing staff should document accurately and as needed in the resident treatment record.
Failure to Develop Comprehensive Care Plan for Language and Communication
Penalty
Summary
The facility failed to develop a comprehensive care plan for language and communication for a resident who only speaks Spanish. During an interview, the resident expressed difficulty in communicating with staff due to the language barrier. The resident's Medicare 5-Day Minimum Data Set (MDS) indicated that Spanish was the resident's primary language, but this information was not included in the resident's care plan. This omission was confirmed during an interview with the MDS Coordinator, who acknowledged that the resident's communication needs were not addressed in the care plan. The facility's policy and procedures for developing care plans require that an individualized, person-centered plan of care be established by the interdisciplinary team (IDT) and updated in accordance with state and federal regulatory requirements. The policy also mandates that the care plan should include measurable objectives and timetables to meet the resident's needs. Despite these requirements, the care plan for the resident did not address the language and communication needs, leading to a deficiency in providing appropriate care for the resident's specific needs.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care services for two residents. Resident #91, who was admitted with acute and chronic respiratory failure and tracheostomy status, had a physician's order for oxygen administration at 4 liters per minute via tracheostomy collar. However, observations on multiple occasions showed the resident receiving oxygen at 5 liters per minute. Additionally, during a tracheal suctioning procedure, an LPN did not follow sterile technique and failed to assess breath sounds before and after the procedure, contrary to the facility's policy and procedures for suctioning ventilator-dependent residents. Resident #96, who had a history of pneumonia, interstitial pulmonary disease, respiratory failure, and tracheostomy status, had a physician's order for oxygen administration at 4 liters per minute via tracheostomy collar. However, observations showed the resident receiving oxygen at 3 liters per minute via nasal cannula. The care plan for Resident #96 indicated the need for oxygen administration as ordered, but staff failed to ensure the correct oxygen rate was administered. The DON confirmed that staff should check and adjust the oxygen rate to match the physician's order.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
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