Aviata At Bryan Dairy
Inspection history, citations, penalties and survey trends for this long-term care facility in Largo, Florida.
- Location
- 9035 Bryan Dairy Rd, Largo, Florida 33777
- CMS Provider Number
- 106116
- Inspections on file
- 24
- Latest survey
- October 24, 2025
- Citations (last 12 mo.)
- 5 (4 serious)
Citation history
Health deficiencies cited at Aviata At Bryan Dairy during CMS and state inspections, most recent first.
A resident with a full code order experienced a significant decline in oxygen saturation and was later found unresponsive. Due to confusion among staff regarding conflicting documentation of code status, CPR was delayed for 45-60 minutes while staff attempted to clarify the resident's wishes, resulting in the resident's death and failure to honor the advance directive.
A resident with a full code status experienced a significant drop in oxygen saturation, which was not reported to the physician or addressed by the LPN. When the resident was later found unresponsive, staff delayed CPR for 45-60 minutes due to confusion over code status, despite documentation confirming full code and no valid DNR. The delay in resuscitation and lack of timely notification to the physician resulted in the resident's wishes not being honored.
A resident with a full code order and clear wishes for resuscitation experienced a significant decline in oxygen saturation that was not reported or addressed. When the resident was later found unresponsive, LPNs delayed CPR due to confusion over code status, despite the absence of a DNR form and the presence of a full code order. This delay, caused by staff reviewing conflicting documentation and seeking guidance instead of immediately starting resuscitation, resulted in a failure to honor the resident's wishes and contributed to the resident's death.
Nursing staff failed to recognize and respond appropriately to a resident's change in condition and code status, resulting in a significant delay in CPR due to confusion over documentation and lack of training. The delay occurred after a resident with complex medical needs was found unresponsive, and staff were unable to promptly determine the correct resuscitation protocol, leading to a failure to honor the resident's wishes and resulting in death.
The facility was found deficient in labeling and dating food items, maintaining cleanliness in the walk-in freezer, and storing personal belongings properly in the kitchen. Opened pasta bags and a container of brown liquid lacked dates, and trash was present on the freezer floor. An unknown food item and cereal container were also undated, and a jacket was improperly stored on a dish rack. The Kitchen Manager confirmed the need for proper labeling and storage practices.
The facility failed to notify residents and/or their representatives of the bed-hold policy during hospital transfers, as required by law. Three residents were transferred without proper documentation of the bed-hold notice being provided. In one case, a notice was partially filled out but lacked a staff signature. The absence of necessary paperwork was confirmed by the Assistant Social Services Director and the Regional Social Services Director.
The facility failed to notify residents and their representatives in writing of transfers or discharges and did not inform the State Long Term Care Ombudsman for three residents reviewed for hospitalization. Documentation was incomplete or missing, and staff interviews confirmed the lack of proper notification and adherence to policy.
The facility failed to enforce its smoking policy, allowing residents to retain smoking materials and smoke unsupervised. Observations showed residents with cigarettes and lighters outside designated times and areas, posing a fire hazard. Staff did not consistently collect smoking materials, and administration was aware of the issue but struggled to enforce compliance.
The facility failed to serve food at safe and appetizing temperatures, as evidenced by two residents being served raw chicken and one receiving a burnt grilled cheese sandwich. A family member reported the raw chicken incident, and the Certified Dietary Manager acknowledged the grievances, confirming that the chicken was not cooked to the required internal temperature of 165 degrees Fahrenheit.
The facility failed to resolve grievances for multiple residents, including issues with cold meals and missing personal belongings. Despite residents voicing concerns, the grievance process was ineffective, with inadequate documentation and follow-up. The facility's grievance log showed unresolved issues with dietary services, and interviews revealed additional grievances that were not properly addressed, indicating systemic issues in grievance handling.
The facility failed to ensure accurate PASARR documentation for four residents, leading to deficiencies in recording mental disorders or intellectual disabilities. A resident with schizoaffective disorder and schizophrenia had an incomplete PASARR, while another with schizophrenia and substance abuse also had missing diagnoses. Additionally, a resident with dementia was inaccurately marked, and another's PASARR was not updated for a new anxiety diagnosis. The DON acknowledged the backlog of incorrect PASARRs needing correction.
The facility failed to maintain the dignity of two residents. One resident, cognitively intact, was left in a hospital gown for three weeks without personal clothing, leading to embarrassment and discomfort. Another resident, severely cognitively impaired, had multiple hospital wristbands causing irritation, which were not removed for three weeks. Staff interviews revealed a lack of awareness and action regarding these issues, and the DON confirmed the absence of a dignity policy.
A resident with moderately impaired cognition was readmitted to the facility without her personal belongings, including clothes, glasses, an air mattress, and fall mats. Despite her requests, staff failed to provide these items, and she was observed wearing a hospital gown. Interviews revealed a lack of awareness and action from staff, and the facility's process for handling personal belongings during transfers was not followed, leading to the deficiency.
A facility failed to complete the necessary Level II PASARR documentation for a resident with Alzheimer's, depression, and mood disorder. The Level I PASARR was initiated late, and the required Level II documentation was not submitted on time. Staff interviews revealed a lack of coordination and responsibility in handling the PASARR process, with the DON admitting to the delay and the Regional SSD acknowledging the lack of qualified personnel.
Two residents in the facility did not receive appropriate ADL care, including showers and bed baths, as per their care plans. One resident, with severe cognitive impairment, was observed in the same gown for days, while another, cognitively intact, reported not receiving showers despite documentation stating otherwise. Staff interviews revealed inconsistencies in documentation and a lack of adherence to care plans, with the DON acknowledging the absence of a policy on ADLs or showers.
A resident with matted hair did not receive necessary assistance with hair care due to staff being too busy, despite having a care plan requiring such help. The resident, who had intact cognition and was admitted with matted hair, had not washed her hair since admission. Staff interviews confirmed the lack of time to assist, and the DON acknowledged the issue was not prioritized. The facility lacked a policy on ADLs and had a closed salon.
A resident with deafness and partial blindness did not receive necessary communication support, as staff were unaware of his needs and lacked training in sign language. The resident's care plan required communication assistance, but no aids or signs were present, leading to his isolation. Facility policy on accommodating hearing-impaired residents was not followed.
The facility failed to monitor behaviors and side effects of psychotropic medications for two residents, leading to a deficiency. One resident with dementia and schizoaffective disorder was on multiple psychotropic drugs, but their MAR lacked monitoring documentation. Another resident with psychosis and depression also had no monitoring records for their prescribed medications. The DON confirmed the lack of adherence to monitoring policies.
A resident with atherosclerosis heart disease and diabetes was not provided with chef salads, which she preferred for weight loss and protein intake. Despite her requests, the facility's menu did not include chef salads, and the Kitchen Manager confirmed that corporate changes had removed them from the menu. The resident's cognitive status was intact, and she expressed dissatisfaction with the meals provided, which lacked protein and were too salty.
A resident was subjected to repeated verbal abuse by another resident, which was witnessed by staff but not effectively addressed. Despite apologies from staff, the incidents continued, and the facility's policy on reporting abuse was not followed, as the Administrator was not informed in a timely manner.
Two residents in a LTC facility received inadequate pressure ulcer care. One resident's heels were improperly offloaded using disposable briefs instead of pressure-relieving boots, leading to stage 4 wounds. Another resident missed multiple wound treatments due to documentation failures, despite having a care plan for pressure injuries and arterial ulcers. The facility's policies on documentation and treatment were not followed, resulting in inadequate care.
Failure to Honor Advance Directives and Timely Initiate CPR
Penalty
Summary
The facility failed to ensure that a resident's advance directives were implemented in a timely manner and did not honor the resident's wishes regarding full code status. A resident with multiple serious diagnoses, including metabolic encephalopathy, multiple sclerosis, sepsis, dysphagia, acute respiratory failure with hypoxia, diabetes type 2, pneumonia, acute kidney failure, myocardial infarct, and hypertension, was documented as cognitively intact and had an active order for full code status. Despite this, when the resident's oxygen saturation dropped to 84% with supplemental oxygen, the LPN on duty did not notify the medical provider or document any interventions regarding this significant change in condition. Later, the resident was found pulseless and not breathing. There was confusion among staff regarding the resident's code status, as conflicting information was found between the hospital transfer form, which indicated DNR, and the facility's electronic health record, which indicated full code. Staff delayed initiating CPR for approximately 45-60 minutes while attempting to clarify the resident's code status, contacting administration, hospice, and the medical team instead of following the full code order present in the record. During this time, no resuscitative efforts were made, and the resident was ultimately pronounced dead. Interviews with staff revealed a lack of clarity and understanding regarding the process for verifying and acting on code status, as well as inconsistent documentation and communication. The facility's policy required that any changes to advance directives be properly documented and communicated, but this was not followed. The failure to promptly initiate CPR in accordance with the resident's documented wishes and physician orders resulted in the resident's wishes not being honored.
Removal Plan
- An audit of each resident's code status was completed.
- The licensed nurse was suspended, pending the facility's investigation.
- A Quality Improvement Performance Committee was conducted to review the recommendations from the root cause analysis.
- A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee.
- Code blue drills were initiated on multiple shifts, with ongoing drills to continue until all staff have completed and with the results reported to the QAPI committee.
- The regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives including identification of a valid DNR and who can initiate a DNR, with a posttest upon completion.
- Licensed nurses and CNAs received education on the CPR policy and procedure including responding to a code blue and the roles/responsibilities during a code.
- Staff received education related to the abuse, neglect, exploitation, and misappropriation policy.
- Licensed nurses received education on the identification of a change in condition including competency.
- Newly hired licensed nurses will receive education upon hire, or accepting a shift, to include the CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.
- Ongoing training is being conducted for the identification of change in condition with competency.
Failure to Provide Timely CPR and Notify Physician of Change in Condition
Penalty
Summary
A deficiency occurred when facility staff failed to provide timely Cardiopulmonary Resuscitation (CPR) to a resident who was found pulseless and not breathing, despite the resident having a documented full code status and no valid Do Not Resuscitate (DNR) order in the medical record. The LPN on duty observed a significant drop in the resident's oxygen saturation to 84% with supplemental oxygen but did not notify the medical provider or document any interventions regarding this change in condition. Later, when the resident was found unresponsive, there was confusion among staff regarding the resident's code status due to conflicting documentation between the hospital transfer form and the facility's records. Multiple staff members, including LPNs and CNAs, reviewed the resident's electronic health record and paper chart, confirming the absence of a DNR form and the presence of a full code order. Despite this, the LPN delayed initiating CPR, instead contacting facility administration, hospice, and the medical team, which resulted in a delay of approximately 45-60 minutes before chest compressions and ventilation were started. During this period, staff were uncertain about the appropriate course of action, and some began preparing for postmortem care before CPR was initiated. The resident had a complex medical history, including metabolic encephalopathy, multiple sclerosis, sepsis, dysphagia, acute respiratory failure with hypoxia, diabetes, pneumonia, acute kidney failure, myocardial infarct, and hypertension. The resident was cognitively intact and had previously expressed a desire to remain full code, as documented in care planning and social service notes. The failure to promptly notify the physician of the change in condition and to honor the resident's advance directive for full code status resulted in the resident's wishes for resuscitation not being honored.
Removal Plan
- An audit of each resident's code status was completed.
- The licensed nurse was suspended, pending the facility's investigation.
- A Quality Improvement Performance Committee (QAPI) was conducted to review recommendations from the root cause analysis.
- A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee.
- Code blue drills were completed for all staff with results reported to the QAPI committee.
- The regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives including identification of a valid DNR and who can initiate a DNR, with a posttest upon completion.
- Licensed nurses and CNAs received education on the CPR policy and procedure including responding to a code blue and the roles/responsibilities during a code.
- Staff received education related to the abuse, neglect, exploitation, and misappropriation policy.
- Licensed nurses received education on the identification of a change in condition including competency.
- Newly hired licensed nurses will receive education to include the CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.
- Ongoing training is being conducted for the identification of change in condition with competency.
Failure to Timely Initiate CPR and Honor Full Code Status
Penalty
Summary
A facility failed to implement timely Cardiopulmonary Resuscitation (CPR) and did not honor a resident's full code status, resulting in a deficiency. The resident, who had a documented full code order and had expressed a desire to be resuscitated, experienced a significant drop in oxygen saturation, which was not reported to a medical provider nor were interventions documented. Later, when the resident was found pulseless and not breathing, staff delayed initiating CPR due to confusion over the resident's code status, despite the absence of a Do Not Resuscitate (DNR) form and the presence of a full code order in the electronic health record. The delay was exacerbated by staff reviewing conflicting documentation and seeking guidance from supervisors and hospice rather than immediately starting resuscitation efforts. One LPN was confused by a hospital transfer form indicating DNR status, but the facility's records and care plan clearly indicated full code. During this period, staff did not promptly call a code or begin chest compressions, and instead contacted administration, hospice, and the medical team, resulting in a delay of approximately 45-60 minutes before CPR was initiated. The resident's medical history included multiple serious conditions such as metabolic encephalopathy, multiple sclerosis, sepsis, dysphagia, acute respiratory failure with hypoxia, diabetes, pneumonia, acute kidney failure, myocardial infarct, and hypertension. The resident was cognitively intact and had actively participated in care planning, consistently expressing a wish to remain full code. The failure to promptly initiate CPR and honor the resident's wishes led to the resident's death and was determined to be an Immediate Jeopardy situation.
Removal Plan
- An audit of each resident's code status was completed.
- The licensed nurse was suspended, pending the facility's investigation.
- A Quality Improvement Performance Committee (QAPI) was conducted to review the incident, discuss corrective actions, and provide recommendations.
- A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee.
- Code blue drills were initiated on multiple shifts and ongoing drills will continue until all staff have completed and will continue with the results reported to the QAPI committee.
- The regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives including identification of a valid DNR and who can initiate a DNR. A posttest was provided upon completion of the education.
- Licensed nurses and CNAs received education on the CPR policy and procedure including responding to a code blue and the roles/responsibilities during a code.
- Staff received education related to the abuse, neglect, exploitation, and misappropriation policy.
- Licensed nurses received education on the identification of a change in condition including competency.
- Newly hired licensed nurses will receive education upon hire, or accepting a shift, to include the CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.
- Ongoing training is being conducted to reach completion for the identification of change condition with competency.
Failure to Ensure Nursing Staff Competency in Code Status Identification and Timely CPR Response
Penalty
Summary
Nursing staff failed to demonstrate competency in identifying a resident's code status, providing timely CPR, and responding appropriately to a change in condition for one resident. The resident, who had multiple complex diagnoses including metabolic encephalopathy, multiple sclerosis, sepsis, acute respiratory failure with hypoxia, and was cognitively intact, experienced a significant drop in oxygen saturation to 84% while on supplemental oxygen. Despite this abnormal reading, the LPN on duty did not notify the medical provider or document any interventions regarding the change in condition. Later, the resident was found pulseless and not breathing. There was confusion among the nursing staff regarding the resident's code status due to conflicting documentation between the hospital transfer form, which indicated DNR, and the facility's electronic health record and care plan, which indicated full code. The LPN and other staff delayed initiating CPR while attempting to clarify the code status, consulting with the DON and other supervisors, and paging hospice. This resulted in a delay of 45-60 minutes before chest compressions and ventilation were started, during which time the resident's wishes for CPR were not honored, and the resident died. Further review revealed that the LPN involved had incomplete orientation records, with no documentation of training on advanced directives, DNR orders, hospice care, respiratory care, vital signs, or change in condition protocols. The facility was unable to confirm whether another LPN had received the required training. Interviews with staff and review of facility policies indicated that prior to the incident, there was a lack of consistent staff training on code blue drills, advanced directives, and change in condition response, contributing to the deficiency.
Removal Plan
- An audit of each resident's code status was initiated and completed.
- The licensed nurse was suspended, pending investigation.
- An ADHOC Quality Improvement Performance Committee (QAPI) was conducted to review recommendations from the root cause analysis.
- A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee.
- Code blue drills were initiated on multiple shifts and will continue until all staff have completed, with results reported to the QAPI committee.
- The regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives including identification of a valid DNR and who can initiate a DNR, with a posttest upon completion.
- Licensed nurses and CNAs received education on the CPR policy and procedure including responding to a code blue and the roles/responsibilities during a code.
- 100% of staff received education related to the abuse, neglect, exploitation, and misappropriation policy.
- Licensed nurses received education on the identification of a change in condition including competency.
- The Human Resource Director will ensure during new hire orientation, newly hired nurses and CNAs are educated on the facility policy related to advanced directives, CPR, and the completed road map from orientation will be signed acknowledging the education received.
- Newly hired licensed nurses will receive education upon hire, or accepting a shift, to include the CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.
Deficiencies in Food Labeling, Cleanliness, and Storage
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items, maintain cleanliness in the walk-in freezer, and store personal belongings appropriately in the kitchen. During an initial tour of the kitchen, two bags of opened pasta and a clear container of brown liquid in the walk-in cooler were found without dates. Additionally, pieces of paper and other trash were observed on the floor of the walk-in freezer, which the Kitchen Manager acknowledged as dirty, noting that it was cleaning day. An unknown food item wrapped in plastic wrap and a container of cereal under the prep table were also found without labels or dates. Furthermore, a jacket was improperly stored, hanging from a dish rack where clean dishes were kept. The Kitchen Manager confirmed that food should be labeled and dated upon opening or placing in a container and that hangers are available for jackets.
Failure to Provide Bed-Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to notify residents and/or their representatives of the bed-hold policy during transfers to the hospital, as required by state and federal law. This deficiency was identified for three residents who were reviewed for hospitalization. Resident #177 was admitted to the facility and later transferred to the hospital due to altered mental status. However, there was no documentation of a bed-hold notice being provided to the resident or their representative at the time of transfer. The facility's administrator confirmed the absence of such documentation. Similarly, Resident #280 was transferred to the hospital, and although a bed-hold notice was partially filled out, it lacked a staff signature to confirm that the notice was provided. Resident #427, who was his own responsible party, was also transferred to the hospital without evidence of receiving a bed-hold notice. The Assistant Social Services Director confirmed the absence of the necessary paperwork and stated that the expectation was for the nurse handling the transfer to initiate the bed-hold paperwork. The Regional Social Services Director also confirmed that the records for these residents did not show that the bed-hold policy was communicated as required.
Failure to Notify Residents and Ombudsman of Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding transfers or discharges, and did not notify the State Long Term Care Ombudsman's Office for three residents reviewed for hospitalization. Resident #177 was transferred to the hospital for altered mental status, but there was no documentation of a Nursing Home Transfer and Discharge Notice or notification to the Ombudsman. Similarly, Resident #280 was transferred twice to a local medical center, but the discharge notices were incomplete, lacking the resident or representative's acknowledgment and the Ombudsman notification. Resident #427 was also transferred to the hospital without a Nursing Home Transfer and Discharge Notice or documentation of Ombudsman notification. Interviews with facility staff, including the Administrator, Assistant Social Services Director, and Social Services Director, confirmed the absence of proper documentation and notification. The facility's policy requires that transfer and discharge notices be documented in the resident's medical record and communicated to the Ombudsman. However, the records for Residents #280 and #427 did not show that the residents or their representatives were notified of the transfers, and the necessary forms were incomplete or missing. The facility's failure to adhere to its policy and federal/state regulations resulted in the deficiency.
Failure to Enforce Smoking Policy and Supervision
Penalty
Summary
The facility failed to ensure that residents returned smoking materials to staff after designated smoking times and upon returning from leave of absence (LOA). Observations revealed that multiple residents were in possession of cigarettes and lighters outside of the designated smoking area and times. Staff were observed not enforcing the policy of collecting smoking materials, allowing residents to retain these items, which led to unsupervised smoking activities. Interviews with staff and residents indicated a lack of adherence to the smoking policy. Residents admitted to keeping cigarettes and lighters on their person to prevent theft, and some were observed exchanging smoking materials among themselves. Staff members acknowledged the issue but did not consistently enforce the policy, allowing residents to smoke unsupervised and retain smoking materials, which were supposed to be stored in a lockbox. The facility's administration was aware of the ongoing issue, as evidenced by discussions in Resident Council Meetings and interactions with the Ombudsman. Despite efforts to address the problem, such as informing residents of the policy and attempting to enforce it, the deficiency persisted. Observations showed cigarette butts in non-designated areas, posing a fire hazard, especially given the dry conditions and burn ban in the county.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to ensure that food was prepared and served at safe and appetizing temperatures, as evidenced by two incidents involving residents being served raw chicken. A family member of one resident reported that during a visit, residents were served raw chicken, and he provided a photo showing red meat on the plate. Another resident expressed frustration over being served raw chicken on two separate occasions and also reported being served a burnt grilled cheese sandwich. Both residents had voiced grievances about the food, but these were not resolved. The Certified Dietary Manager (CDM) acknowledged receiving grievances related to the raw chicken and confirmed that the chicken was not served at the correct temperature. The CDM admitted that the chicken should have been cooked to an internal temperature of 165 degrees Fahrenheit, as per the facility's policy. Additionally, the CDM recognized that the grilled cheese sandwich served was burnt and should not have been sent out. The facility's policy on food preparation, revised in February 2023, mandates that all poultry and stuffed foods be cooked to a minimum internal temperature of 165 degrees Fahrenheit.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility failed to adhere to its grievance policy, resulting in unresolved grievances for multiple residents. During a Resident Council meeting, 11 out of 13 residents expressed ongoing dissatisfaction with receiving cold meals, a concern that had persisted for months. Despite being informed that tray warmers would be acquired, the issue remained unresolved. Residents reported that while grievances were accepted, the resolution process was ineffective, and they were no longer provided with copies of their grievances. The facility's grievance log revealed multiple entries related to cold food, with investigations indicating that the pellet warmer was malfunctioning and awaiting repair. Further interviews highlighted additional grievances that were not adequately addressed. One resident reported missing clothing and a broken TV upon returning from a hospital stay, with no follow-up from the facility despite the involvement of the Ombudsman. Another resident experienced a room change during which personal belongings went missing, and no grievance was filed or followed up on by the facility. The Social Services Director confirmed the lack of documentation for these grievances, indicating a breakdown in the grievance process. The facility's failure to resolve grievances and provide follow-up communication with residents demonstrates a significant deficiency in adhering to its grievance policy. The lack of effective resolution and documentation of grievances, particularly concerning dietary issues and personal belongings, highlights systemic issues within the facility's grievance handling procedures. The Administrator and Social Services Director were aware of these issues but failed to ensure proper documentation and resolution, contributing to ongoing resident dissatisfaction.
Inaccurate PASARR Documentation for Residents
Penalty
Summary
The facility failed to ensure accurate Level I Preadmission Screening and Resident Review (PASARR) for four residents, leading to deficiencies in the documentation of mental disorders or intellectual disabilities. Resident #20 was admitted with diagnoses including schizoaffective disorder and schizophrenia, but their PASARR did not mark these conditions. Similarly, Resident #96, admitted with schizophrenia and substance abuse, had an incomplete PASARR that failed to reflect these diagnoses. The Director of Nursing (DON) acknowledged the absence of a dedicated staff member to review PASARRs and identified a backlog of incorrect PASARRs needing correction. Resident #36 was admitted with a primary diagnosis of unspecified dementia, but their PASARR inaccurately marked 'no' for a primary diagnosis of dementia. Additionally, Resident #42, who had diagnoses including bipolar disorder and PTSD, did not have their PASARR updated to include a new diagnosis of anxiety disorder. The DON expressed an expectation for all diagnoses to be listed on the PASARR and noted that a Level II assessment should be completed for residents with a primary diagnosis of dementia.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of two residents, leading to deficiencies in their care. Resident #16 was observed wearing a hospital gown with inadequate coverage, exposing her skin, and had matted, unkempt hair. Despite being cognitively intact, she reported not having personal clothing for three weeks and expressed embarrassment about her appearance. Interviews with staff revealed that although there were donated clothes available, Resident #16's needs were not adequately addressed, and the Director of Nursing was unaware of the situation. Resident #32 was found wearing a hospital gown and multiple wristbands from a previous hospital stay, which were causing irritation. The resident, who was severely cognitively impaired, had been in the facility for three weeks without the wristbands being removed. Staff interviews indicated that the wristbands should have been removed upon admission, but this was overlooked. The Director of Nursing acknowledged the oversight and confirmed the absence of a facility policy on dignity.
Failure to Provide Resident with Personal Belongings Upon Readmission
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #43, had access to her personal belongings upon readmission after a hospitalization. The resident, who had moderately impaired cognition, reported not having her clothes, glasses, air mattress, and fall mats, which were essential for her care due to her medical condition. Despite her requests to the staff, these items were not provided, and she was observed wearing a hospital gown. Interviews with various staff members, including a Licensed Practical Nurse, Certified Nursing Assistant, and Therapy Assistant, revealed a lack of awareness and action regarding the resident's missing belongings. The staff acknowledged that the resident's personal items should have been retrieved from storage and returned to her room upon readmission. The facility's process for handling personal belongings during a resident's transfer was not followed, as confirmed by interviews with the Assistant Social Services Director, Regional SSD, Director of Nursing, and Nursing Home Administrator. The facility's policy required personal items to be boxed, inventoried, and stored securely during a resident's absence, with the expectation that they would be returned upon readmission. However, the staff failed to execute this process, resulting in the resident's continued lack of access to her personal effects, including her glasses, which were still missing despite efforts to locate them. The facility's failure to adhere to its policy and ensure the resident's right to personal belongings led to the deficiency identified in the report.
Failure to Complete PASARR Documentation
Penalty
Summary
The facility failed to complete the necessary Level II Preadmission Screening and Resident Review (PASARR) documentation for a resident diagnosed with Alzheimer's disease, depression, and unspecified mood affective disorder. Upon review, it was found that a Level I PASARR was not conducted at the time of the resident's admission, and it was only initiated several days later. The Level I PASARR indicated that the resident exhibited behaviors that posed a danger to themselves or others, necessitating a Level II evaluation. However, the required documentation for the Level II PASARR was not submitted in a timely manner. Interviews with facility staff revealed a lack of coordination and responsibility in handling the PASARR process. The Director of Nursing (DON) admitted to initiating the Level I PASARR late and failing to submit the necessary paperwork for the Level II evaluation. The Regional Social Services Director also acknowledged the delay in submitting the Level II documentation, attributing it to a lack of qualified personnel in the Social Services Department at the time. The facility's policy mandates that all residents with serious mental illness or intellectual disabilities receive appropriate pre-admission screenings, which was not adhered to in this case.
Deficiency in Providing ADLs and Inadequate Documentation
Penalty
Summary
The facility failed to ensure that Activities of Daily Living (ADLs) were appropriately provided for two residents. Resident #32, who was readmitted with diagnoses including anemia, dementia, and morbid obesity, was observed in a hospital gown and reported not receiving showers or being assisted out of bed. Documentation indicated she had only two showers and two bed baths since her readmission, despite being scheduled for more frequent showers. Staff interviews revealed inconsistencies in documentation, with a Registered Nurse confirming the resident had been in the same gown all day and no shower sheets were available to verify care provided. Resident #68, readmitted with conditions such as sepsis and depression, reported not receiving showers and only minimal cleaning. Her care plan required assistance for bathing, but documentation showed she had several showers and bed baths, which she disputed. Staff interviews highlighted issues with documentation and adherence to care plans, with the Director of Nursing stating that showers should be documented only if performed. The facility lacked a policy on ADLs or showers, contributing to the deficiency.
Failure to Assist Resident with Hair Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for a resident who was unable to care for herself, specifically in relation to hair care. The resident, who had been admitted with matted hair following a lengthy hospitalization, expressed that she had been requesting help with her hair since her admission nearly two months prior. Despite having a cognitive status indicating intact cognition and a care plan that required staff assistance for personal hygiene, the resident's hair remained matted and tangled. The resident reported that staff were too busy to assist her, and she had not washed her hair since admission due to concerns about it not drying properly. Interviews with staff, including a CNA and the Director of Nursing (DON), confirmed the resident's need for assistance and the lack of time available to provide it. The CNA acknowledged the difficulty in managing the resident's hair among other duties, while the DON admitted to only recently becoming aware of the issue. The DON also mentioned that a concierge had been hired to help with such tasks, but the resident's hair care was not prioritized due to other higher care needs. The Nursing Home Administrator (NHA) noted the absence of a policy on ADLs and the closure of the facility's salon, which contributed to the deficiency in care.
Failure to Provide Communication Support for Deaf and Blind Resident
Penalty
Summary
The facility failed to ensure that a resident with significant communication impairments received the necessary support to maintain communication abilities. The resident, who was deaf and partially blind, was observed without any communication assistive devices or personal effects that would aid in communication. The resident's care plan indicated the need for assistance with communication, including the use of American Sign Language (ASL) and a translator, but these interventions were not observed to be in place. Interviews with staff revealed a lack of awareness and training in communicating with the resident. Certified Nursing Assistants (CNAs) and a Registered Nurse (RN) admitted to guessing the resident's needs and were unaware of the resident's communication methods, such as sign language. The RN was not informed of the resident's deafness and did not know how to communicate effectively with him. There were no signs or indicators in the resident's room to inform staff or visitors of his communication preferences, and the staff did not utilize available resources to facilitate communication. The facility's policy on accommodating hearing-impaired residents was not followed, as staff did not consult with the resident or his family to determine necessary auxiliary aids. The policy outlined steps such as facing the resident when speaking and providing writing materials, but these were not implemented. The lack of effective communication aids and staff training resulted in the resident being isolated and unable to engage with others, as observed during the survey period.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to monitor behaviors and side effects of psychotropic medications for two residents, leading to a deficiency in medication management. Resident #36, who was admitted with diagnoses including unspecified dementia, schizoaffective disorder, and major depressive disorder, was prescribed multiple psychotropic medications such as Cymbalta, Risperdal, Seroquel, and Wellbutrin XL. However, the Medication Administration Record (MAR) for April, May, and June 2024 did not show any monitoring of behaviors and side effects for these medications, as required by the facility's policies. Similarly, Resident #77, admitted with diagnoses of unspecified psychosis and major depressive disorder, was prescribed Amitriptyline and Buspirone. The MAR for the same period also lacked documentation of behavior and side effect monitoring for these medications. The care plans for this resident included interventions to monitor for anxiety-related behaviors and side effects from medications, but these were not followed. The Director of Nursing confirmed that there should have been orders for behavior and side effect monitoring, which were not executed as per the facility's policy.
Failure to Accommodate Resident Dietary Preferences
Penalty
Summary
The facility failed to accommodate the dietary preferences of a resident who expressed a need for chef salads to aid in weight loss. The resident, who had a diagnosis of atherosclerosis heart disease and diabetes, reported that the facility no longer served chef salads, which she preferred for their protein content. Despite her requests and messages to the Kitchen Manager, she continued to receive meals that did not meet her dietary preferences, such as chicken broth, which she found too salty and lacking in protein. The resident's cognitive status was intact, as indicated by a BIMS score of 15 out of 15, and she weighed 224 pounds at the time of the survey. The facility's menu did not list chef salads, and the always available menu also lacked this option. The Kitchen Manager confirmed that the menu had been changed by corporate, and chef salads were no longer offered. The Food Committee Meeting Minutes from earlier in the year showed requests for more chef salads, indicating ongoing resident dissatisfaction with the menu options. The Kitchen Manager also noted that the resident did not like several types of meat, which further complicated her dietary needs. The Administrator was unaware of why the resident could not receive a chef salad and needed to investigate further.
Failure to Prevent Repeated Verbal Abuse Between Residents
Penalty
Summary
The facility failed to protect a resident from repeated incidents of verbal abuse by another resident. Resident #34 reported being verbally assaulted by Resident #96 at the nursing station while receiving medication. Staff A, an LPN, witnessed the incident and apologized to Resident #34 but did not take further action to prevent future occurrences. Resident #34 expressed frustration over the repeated verbal attacks and the lack of effective intervention by the staff, as previous incidents had also occurred. Staff B, an LPN and Unit Manager, intervened during the altercation by instructing Resident #96 to walk away, but did not report the incident to the Administrator as required by the facility's policy. The Administrator, who also serves as the Risk Manager, was unaware of the incident until interviewed and stated that it should have been reported immediately. The facility's policy mandates that any knowledge of abuse or allegations must be reported within specific timeframes, which was not adhered to in this case.
Inadequate Pressure Ulcer Care and Documentation Failures
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent the worsening of pressure wounds for two residents. Resident #74 was observed lying in bed with bandages on both heels, propped up on a plastic pack of disposable briefs instead of using pressure-relieving boots. Staff confirmed that the boots were in the laundry, and the use of briefs for offloading was inappropriate. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease and muscle weakness, and had severely impaired cognition. The resident's physician orders required offloading of the heels, but the improper method used led to the worsening of the wounds to stage 4. Resident #12, who was cognitively intact, had a care plan for pressure injuries and arterial ulcers with specific wound care orders. However, the Treatment Administration Record showed multiple missed wound treatments in May and June. The Director of Nursing initially suspected documentation errors, but Resident #12 confirmed that wound treatments were not provided over a weekend. The facility's policies required accurate and timely documentation of wound care, which was not adhered to, leading to a failure in providing necessary wound care. The facility's policies and job descriptions emphasized the importance of proper documentation and compliance with treatment guidelines. Despite these policies, the nursing staff failed to document wound treatments accurately, and inappropriate methods were used for pressure ulcer care. These deficiencies highlight a lack of adherence to established protocols, resulting in inadequate care for residents with pressure wounds.
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Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
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