Aviata At Brentwood
Inspection history, citations, penalties and survey trends for this long-term care facility in Lecanto, Florida.
- Location
- 2333 N Brentwood Cir, Lecanto, Florida 34461
- CMS Provider Number
- 105461
- Inspections on file
- 25
- Latest survey
- December 12, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Aviata At Brentwood during CMS and state inspections, most recent first.
A resident's representative was not promptly notified after the resident sustained a fall. Documentation showed missing contact information, and interviews confirmed that the family only learned of the incident after observing injuries during a visit and contacting the unit manager. Facility policy requires immediate notification of such events, but this was not carried out.
Two residents did not receive restorative nursing care as recommended by therapy upon discharge, due to the absence of a restorative nursing program. The DON and Rehabilitation Director confirmed the lack of restorative services, despite facility policy requiring such care to maintain or improve residents' range of motion and mobility.
A resident with diabetes and other complex conditions had a significantly elevated Hemoglobin A1C result, but there was no documentation that the physician was notified of this critical lab finding. Insulin management orders were made much later, and both the DON and physician confirmed the result was not communicated in a timely manner.
A resident receiving hemodialysis was not accurately documented as such in the MDS assessment, as Section O for special treatments was not checked. Both the DON and the MDS RN confirmed the resident was a dialysis patient and that the assessment should have reflected this.
A resident with physician-ordered parameters for Midodrine HCl to treat hypotension did not receive the medication despite blood pressure readings that met the criteria for administration. The MAR showed no documentation of the medication being given, and interviews with an LPN and other staff confirmed the omission and lack of adherence to the physician's order.
The facility did not maintain accurate or complete medical records for three residents, including incorrect fall risk assessment after a significant fall, missing documentation of wound care treatments, and incomplete records regarding medication administration and follow-up for a resident experiencing nausea. Interviews with the DON and nursing staff confirmed documentation lapses and inconsistencies.
A resident with multiple complex medical conditions was discharged home after insurance ended skilled service coverage. The case manager arranged for home health care but did not verify that services were initiated, failing to make the required follow-up call as outlined in facility policy. This resulted in the resident not receiving expected home health services post-discharge.
A resident with a PICC line was found with a dressing that had not been changed as per physician orders, which required a change within 24 hours of admission and weekly thereafter. Staff interviews confirmed the oversight, and the Treatment Administration Record showed the dressing was not changed every seven days as required. The DON acknowledged the expectation for timely dressing changes, which was not met.
The facility failed to enforce its smoking policy, allowing residents to possess vaping devices outside designated areas and times. Observations revealed that several residents had vaping devices in their rooms, contrary to the policy requiring storage by nursing staff. The DON acknowledged the issue, indicating ongoing efforts to address compliance.
The facility failed to refer two residents for a Level II PASRR evaluation despite their psychiatric diagnoses. One resident had unspecified psychosis and brief psychotic disorder, while another had pseudobulbar affect, delusional disorders, and unspecified psychosis. The Level I PASRRs did not document these conditions, incorrectly indicating that no further evaluation was needed. The DON acknowledged the inaccuracies.
The facility failed to ensure accurate assessments for residents, leading to discrepancies in records. A resident was discharged to an Assisted Living Facility, but the MDS inaccurately documented the discharge as to a hospital. Another resident's diet order was not correctly reflected in the MDS. Additionally, a resident's fall was not accurately recorded in the MDS, despite documentation of the incident. These errors were confirmed by the MDS Coordinator.
A resident with a forehead wound did not receive wound care as per physician's orders, with observations showing an unchanged bandage held by dried blood. The facility's policy requiring daily dressing changes was not followed, and documentation was missing for one day. Interviews confirmed the lapse in care.
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in documentation and medication administration. One resident's MAR lacked documentation for the application of a prescribed barrier cream, while another resident received medication outside the prescribed time due to a transcription error. The DON acknowledged these issues, highlighting lapses in adherence to facility policies on documentation and physician orders.
A facility failed to ensure proper infection control during wound care for residents on enhanced barrier precautions. Staff did not consistently perform hand hygiene or use appropriate PPE, such as gowns, when providing care. Observations revealed that a Wound Care LPN did not perform hand hygiene between different stages of wound care and after touching potentially contaminated surfaces. The facility's policies require the use of gloves and gowns for high-contact care activities and emphasize hand hygiene, which were not followed, leading to a deficiency.
The facility did not maintain a clean and homelike environment in one of its main hallways, where a water leak and black substance were observed on the ceiling. A resident highlighted the issue, and the Maintenance Director confirmed the leak had been ongoing. The Resident Council President noted that concerns about the leak and mold had been reported to management for a long time. The facility's maintenance policy, which requires preventive maintenance and prompt repairs, was not followed.
The facility did not post nurse staffing information daily as required. On a Monday, it was found that the information displayed was from the previous Friday. The DON confirmed the lapse and noted that the weekend supervisor was responsible for updates. The facility lacked a specific policy for posting this information, relying on federal regulations.
Failure to Notify Resident Representative of Fall Incident
Penalty
Summary
The facility failed to notify the resident representative of a fall sustained by a resident. Record review showed that the resident experienced a fall, which was documented on an SBAR Communication form. The form indicated that the resident's representative was listed as the emergency contact, but no phone numbers were provided for either the representative or the resident's daughter, making it impossible to contact the family. The form was signed by an LPN, but there was no documentation that the family had been notified of the incident. Interviews revealed that the resident's granddaughter was not informed of the fall at the time it occurred. She discovered her grandmother's injuries upon visiting and subsequently contacted the unit manager via facetime, at which point she was informed of the fall. The LPN involved stated that she did not know about the fall until checking the computer after being contacted by the granddaughter. Another LPN could not recall if the family had been contacted. Facility policy requires prompt notification of the resident representative and attending physician in the event of accidents, but this procedure was not followed in this case.
Failure to Provide Restorative Nursing Services as Recommended by Therapy
Penalty
Summary
The facility failed to provide restorative nursing care and services as recommended by the therapy department for two residents. For one resident, the occupational therapy discharge summary recommended a restorative bed mobility program to maintain the current level of functioning, but there was no documentation in the clinical record indicating that restorative nursing was provided. The DON confirmed that the resident did not receive restorative nursing as recommended and acknowledged that the facility did not have a restorative nursing program in place at the time. For another resident, the physical therapy discharge summary indicated that the resident was discharged from therapy with a recommendation for a restorative nursing program due to ongoing risks such as knee buckling and fluctuating respiratory deficits. The resident reported not having therapy for a while and expressed interest in receiving it. The Rehabilitation Director stated that the resident was recommended for restorative care but was unaware that the facility lacked a restorative program. The DON confirmed that the facility had not had a restorative program for several months, despite facility policy stating that restorative nursing services should be provided to encourage and enable residents to be as independent as possible.
Failure to Notify Physician of Critical Lab Result
Penalty
Summary
The facility failed to take timely action on laboratory test results for one resident who was admitted with multiple complex diagnoses, including type 2 diabetes mellitus with hyperglycemia, anemia, chronic kidney disease, and a recent urinary tract infection. Upon admission, a physician ordered a Hemoglobin A1C test to monitor the resident's diabetes management. The lab result, reported two days later, showed a significantly elevated Hemoglobin A1C of 10.8. However, there was no documentation in the nursing progress notes that the physician was notified of this result. Subsequent physician orders for insulin management were made nearly two weeks after the lab result was available, with no evidence that the elevated A1C was communicated to the physician in a timely manner. During interviews, the DON acknowledged that the physician should have been notified of the results, and the physician could not recall being informed of the lab findings. This lack of timely notification and action on critical laboratory results constituted a deficiency in the facility's laboratory services for the resident.
Inaccurate MDS Assessment for Dialysis Patient
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for one resident receiving dialysis. Record review showed that the resident had a physician's order for hemodialysis three times per week. However, the resident's quarterly MDS assessment did not indicate that dialysis was being received under Section O, which covers special treatments, procedures, and programs. During interviews, both the Director of Nursing and the MDS Registered Nurse confirmed that the resident was a dialysis patient and acknowledged that Section O should have been marked accordingly, in line with the RAI manual requirements.
Failure to Administer Blood Pressure Medication per Physician Order
Penalty
Summary
A deficiency occurred when a resident did not receive blood pressure medication as ordered by the physician. The physician's order specified that Midodrine HCl 5 mg should be administered orally every 12 hours as needed for hypotension, specifically when the resident's systolic blood pressure was less than 110 mmHg and diastolic blood pressure was less than 60 mmHg. On a specific date, the resident's blood pressure readings were 105/54 mmHg and 102/50 mmHg, both meeting the criteria for medication administration. However, review of the Medication Administration Record (MAR) showed no documentation that the medication was given on that day. Interviews with facility staff revealed that the LPN responsible for the resident did not recall why the medication was not administered and stated that if it had been given, it would have been documented. The Advanced Practice Registered Nurse confirmed that the medication was available and that the parameters for administration were clear. The Director of Nursing also acknowledged that the medication should have been given according to the established parameters. Facility policy required review and adherence to physician orders, which was not followed in this instance.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to ensure the accuracy and completeness of medical records for three residents. For one resident, an incident report documented a significant fall with injuries, including a laceration, hematoma, and fractures. However, the resident's subsequent fall risk evaluation incorrectly indicated no history of falls within the past six months, despite the recent incident. The Director of Nursing acknowledged the inaccuracy in the fall risk assessment. Another resident had multiple physician orders for wound care, including specific instructions for the sacrum and right lateral thigh. The Treatment Administration Records (TAR) for this resident showed several dates with missing documentation for wound care treatments. The wound care nurse noted that the resident sometimes refused care, but since the nurse had been providing care, there were no refusals. The Director of Nursing confirmed that treatment records should not have blanks and that refusals or care provided should be documented accordingly. A third resident's Medication Administration Record (MAR) indicated that aspirin was not administered due to nausea, but the progress note only mentioned that the medication was not on hand and that the provider would be contacted. Interviews with the DON and the nurse involved revealed inconsistencies in documentation regarding whether the provider was contacted and the resident's subsequent status. The DON stated that the nurse should have documented her follow-up actions, and the Regional Nurse Consultant noted the absence of a documentation policy.
Failure to Follow Discharge Follow-Up Policy for Discharged Resident
Penalty
Summary
The facility failed to follow its discharge policy for ensuring follow-up with discharged residents, as evidenced by the case of one resident who was discharged home after insurance discontinued payment for skilled services. The resident had multiple complex medical diagnoses, including sepsis, acute respiratory failure with hypoxia, type 2 diabetes with ketoacidosis and hyperglycemia, morbid obesity, and recent surgical aftercare. The case manager arranged for home health care through the resident's insurance company, which provided a reference number for services. However, it was later discovered that home health services had not been set up due to limitations in the resident's insurance plan. Despite the facility's policy requiring a follow-up call within 24 to 48 hours after discharge to verify that community services were in place, the case manager did not contact the resident post-discharge to confirm that home health services were being provided. The omission was acknowledged by the case manager, who stated that the follow-up call was simply forgotten. The Director of Nursing and Administrator both confirmed that the expectation was for follow-up contact to be made with discharged residents, but this did not occur in this instance.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to provide care and services for a PICC access device in accordance with professional standards of practice for a resident. The resident was re-admitted to the facility with a diagnosis that included intraspinal abscess, granuloma, osteomyelitis, and a urinary tract infection. Upon observation, the resident was found with a PICC line in the upper right arm, covered by a transparent dressing dated 2/9/2025. The resident reported that the dressing had only been changed once since admission, contrary to the physician's orders which required the dressing to be changed within 24 hours of admission and weekly thereafter. Interviews with facility staff revealed that the dressing change was overlooked. An LPN admitted to administering medication through the line without noticing the outdated dressing, and the Unit Manager confirmed the dressing had not been changed as required. The Treatment Administration Record for February 2025 corroborated that the dressing change was not completed every seven days as ordered. The Director of Nursing acknowledged the expectation for the dressing to be changed within 24 hours after admission and then weekly, which was not adhered to, resulting in the deficiency.
Failure to Enforce Smoking Policy for Vaping Devices
Penalty
Summary
The facility failed to adhere to its smoking policy, specifically regarding the use of vaping devices by residents. During observations, it was noted that several residents, identified as Resident #3, #15, #35, and #61, had vaping devices in their possession outside of designated smoking times and areas. Resident #3 had a vaping device in their room, which was not stored in the designated smoking box as required. Similarly, Resident #35 was observed with a vaping device on their bedside table and admitted to using it in their room, contrary to the facility's policy. Resident #15 also had a vaping device on their bed, which they handed over to the Director of Nursing (DON) upon request. Resident #61 initially refused to surrender their vaping device, stating they had not agreed to any policy restricting its possession. The facility's policy mandates that electronic cigarettes and related materials be stored by nursing staff and only used in designated smoking areas during authorized times. However, the observations and interviews revealed that these policies were not being enforced, as residents were found with vaping devices in their rooms and outside of designated smoking times. The DON acknowledged the issue, noting that the facility was aware of the problem and working towards compliance. The facility's failure to enforce its smoking policy resulted in residents having unrestricted access to vaping devices, which was against the established procedures.
Failure to Refer Residents for Level II PASRR Evaluation
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident #38 and Resident #22, were referred for a Level II Preadmission Screening and Resident Review (PASRR) evaluation and determination, as required. Resident #38 was admitted with a diagnosis of unspecified psychosis, and a psychiatry progress note later confirmed a diagnosis of brief psychotic disorder. However, the Level I PASRR completed by the facility staff did not document the resident's psychiatric diagnosis, incorrectly indicating that no Level II PASRR evaluation was required. Similarly, Resident #22 was admitted with diagnoses including pseudobulbar affect, delusional disorders, and unspecified psychosis. A psychiatry care plan note confirmed these diagnoses, yet the Level I PASRR also failed to document these conditions, again incorrectly stating that no Level II PASRR evaluation was necessary. During an interview, the Director of Nursing acknowledged that the PASRRs for both residents were inaccurate and needed correction.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments for several residents, leading to discrepancies in their records. Resident #102 was admitted and discharged to an Assisted Living Facility, but the Minimum Data Set (MDS) inaccurately documented the discharge as to a short-term general hospital. This error was confirmed by the MDS Coordinator during an interview. Similarly, Resident #2 had a physician's order for a Controlled Carbohydrate Diet with chopped meats, but the MDS inaccurately indicated that the resident did not require a mechanically altered diet. This was also verified by the MDS Coordinator. Additionally, Resident #10's records showed inconsistencies regarding fall incidents. Although the resident had a documented fall on April 24, 2024, the annual MDS inaccurately stated that there were no falls since admission. The resident's care plan indicated a risk for falls due to various health conditions, and the MDS Coordinator acknowledged the incorrect coding. These inaccuracies highlight the facility's failure to maintain accurate and up-to-date assessments for its residents, as required by their policy and procedure for MDS assessments.
Failure to Adhere to Wound Care Protocols
Penalty
Summary
The facility failed to provide wound care treatment in accordance with professional standards for a resident with a skin condition. During observations on two consecutive days, the resident was found with a bandage on her forehead that was not properly adhered, being held in place by dried blood from the wound. The bandage was dated for two days prior, indicating it had not been changed as per the physician's order, which required daily dressing changes. Additionally, there was no documentation of the wound care being administered on one of the days, as noted in the Treatment Administration Record. Interviews with the Director of Nursing and the Wound Care LPN revealed that the dressing was not changed on one of the days, and the system used to track wound care orders indicated that the dressing change had not been completed. The facility's policy on dressing changes, which mandates that a clean dressing be applied as ordered to promote healing, was not followed. This lapse in care was identified as a deficiency in the facility's adherence to professional standards of practice for wound care.
Deficiencies in Medical Record Accuracy and Medication Administration
Penalty
Summary
The facility failed to ensure accurate medical records for two residents, leading to deficiencies in documentation and medication administration. For one resident with a skin condition, the physician's order required the application of a house barrier cream to a sacral wound three times a day and as needed. However, the Medication Administration Record (MAR) showed multiple instances where the application was not documented over several months. The Director of Nursing acknowledged that the application was being done, but staff failed to document it in the MAR, which is expected when an order is present. Another resident had a physician's order for Midodrine HCl to be administered every eight hours, with specific instructions not to administer past 6 PM and to hold the medication if blood pressure exceeded 110. Despite this, the MAR indicated that the medication was administered at 10:00 PM on several occasions. The Director of Nursing identified this as a transcription error. The facility's policies on documentation and physician orders emphasize the importance of accurate and timely record-keeping, which was not adhered to in these cases.
Infection Control Deficiency in Wound Care Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during wound care for residents on enhanced barrier precautions. Specifically, staff did not consistently perform hand hygiene or use appropriate personal protective equipment (PPE) such as gowns when providing care to residents with open wounds. During an observation, a Wound Care LPN and a CNA entered a resident's room without enhanced barrier precautions signage or PPE available. Although they performed hand hygiene and donned gloves, they did not wear gowns. The LPN failed to perform hand hygiene between different stages of wound care, such as after removing gloves and before donning new ones, and after touching potentially contaminated surfaces like the resident's briefs. In another instance, the same LPN and CNA donned gloves and gowns before entering another resident's room. However, the LPN did not perform hand hygiene after removing gloves and before opening gauze packets, nor between different stages of wound care. The LPN acknowledged the failure to perform hand hygiene after cleaning wounds and when changing gloves. The Director of Nursing confirmed that staff are expected to don gloves and gowns for residents on enhanced barrier precautions and perform hand hygiene after cleaning wounds and when changing gloves. The facility's policies and procedures for enhanced barrier precautions, dressing changes, and hand hygiene were reviewed. These policies require the use of gloves and gowns for high-contact care activities and emphasize the importance of hand hygiene after contact with wounds or removal of gloves. The facility's failure to adhere to these protocols during wound care for residents on enhanced barrier precautions was identified as a deficiency.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in one of its main hallways, as evidenced by a water leak and the presence of a black substance on the ceiling. This issue was observed in the hallway between the main dining room and the 400 Hall. A resident pointed out the black substance on the ceiling, indicating it should be cleaned off. The Maintenance Director confirmed the existence of a roof leak above the hallway, acknowledging it had been a persistent issue. Additionally, the Resident Council President reported that concerns about water leaks and mold in the hallway had been communicated to management for a long time. The facility's policy on maintenance, which includes preventive maintenance and prompt action to repair issues, was not adhered to, as daily rounds by the Director of Environmental Services failed to address the hazard.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted on a daily basis, as required by federal regulation. On Monday, August 12, 2024, at 5:59 AM, it was observed that the nurse staffing information displayed in the front lobby was outdated, showing details from Friday, August 9, 2024. During an interview on the same day at 7:00 AM, the Director of Nursing confirmed that the information had not been updated daily and attributed the responsibility to the weekend supervisor. Further, during an interview on August 14, 2024, at 12:02 PM, the Director of Nursing admitted that the facility did not have a specific policy for posting nurse staffing information, instead relying on federal regulations.
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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